See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/303444458

ANESTHETIC CONSIDERATIONS IN THE GERIATRIC PATIENT

Presentation · October 2015

DOI: 10.13140/RG.2.1.5082.4567

CITATIONS READS
0 2,062

1 author:

John B. Leslie
Mayo Clinic - Scottsdale
65 PUBLICATIONS   1,668 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Postoperative Nausea and Vomiting View project

Alvimopan Entereg View project

All content following this page was uploaded by John B. Leslie on 23 May 2016.

The user has requested enhancement of the downloaded file.

 ANESTHESIOLOGY
Volume 58, Issue 21
ANESTHETIC CONSIDERATIONS IN THE GERIATRIC PATIENT
From the Scottsdale Anesthesia Conference, presented by Holiday Seminars
John B. Leslie, MD, MBA, Professor of Anesthesiology, Mayo Clinic Medical School, Scottsdale, AZ;
Staff Anesthesiologist, Mayo Clinic Arizona;
Clinical Professor of Anesthesiology, University of Arizona School of Medicine, Phoenix
Aging: intrinsic, progressive process; genetic and lifestyle influ-
ences lead to variable rates of aging; aging can be defined on
cellular level by, eg, analyzing messenger RNA and capabili-
ties for replenishment; aging occurs in every organ; initially
evident as failure of homeostatic maintenance; historical per-
spective — in 1800, many deaths during first 2 yr of life; in
1900s, majority of people died <60 yr of age; however, not
much progress since 1960s to 1980s after development of cures
for most infectious diseases and treatments of common prob-
lems (eg, cardiovascular disease); few survive beyond age 90;
on average, women live longer than men
Implications for health care: with baby boomers aging, impact
seen in orthopedics, gynecology, urology, and cancer surgery;
surgical treatment of cardiovascular conditions has plateaued
because of development of drugs and innovations in nonop-
erative treatments; aging of baby boomers will significantly
increase number of elderly patients requiring surgery and anes-
thesia; illness in geriatric patients — ≥80% of individuals >65
yr of age have one chronic health problem; malnourishment
(as defined by laboratory testing) occurs in 40% (primarily due
to not eating healthy foods); 70% of individuals >65 yr have
2 diagnosed chronic diseases; geriatric patients account for
one-third of all operations in United States, and predicted that
within next 10 to 15 yr they will account for half of all opera-
tions; geriatric patients account for one-third of health care
dollars, and figure will reach one-half in 10 to 15 yr; geriatric
patients already consume >50% of federal health care money;
baby boomers account for two-thirds of cancers and >2 mil-
lion inpatient admissions/day; patients >65 yr of age likely to
undergo major operation (eg, cancer surgery, cardiac proce-
dure, repair of hip fracture, replacement of knee) during year
of death; United States spends considerable amount of money
on health care (≈$7300/person/yr), but life expectancy not as
high as in many other countries
Outcomes in geriatric patients: much more likely to suffer
adverse outcomes after surgery; patient in late 90s has almost
63% risk of not surviving 30 days after major operation;
patients >65 yr of age often have prolonged and difficult pat-
terns of recovery that can last many months; mortality from
simple procedures in patients in their 90s >10%; each decade
increases risk for death by factor of 1.75; after high-risk cancer
procedures, eg, lung resection, pancreatic resection, or explor-
atory laparotomy, 30-day mortality >20%
Educational Objectives
The goal of this program is to improve the anesthetic care of
geriatric patients. After hearing and assimilating this program,
the clinician will be better able to:
1. Clarify the risks of surgery and anesthesia in geriatric
patients.
2. Outline the changes in organ systems that occur in
elderly individuals.
3. Explain the effects of aging on the pharmacodynamic
properties of anesthetic agents.
4. Choose an anesthesia plan for geriatric patients.
5. Manage postoperative cognitive dysfunction.
June 7, 2016
Deterioration in health: one-half of individuals able to live
independently at age 65; aging manifested as progressive dete-
rioration of functional reserve capacity (eg, reduced ability to
perform activities without shortness of breath); surgery and
anesthesia cause physiologic challenge; noticeable difference
in functional reserve starts occurring at ages 45 to 50; function
of every organ declines; when disease first noticed, therapy
may be able to restore function to near normal; treatment may
also rescue patients with exacerbations and improve function;
however, progressive disease or exacerbation in organ with
insufficient function eventually causes death; effects of aging
on organ function — every organ starts to deteriorate almost
1%/yr starting at age 20 to 30 (as measured by, eg, nerve con-
duction velocity, basal metabolic rate, cardiac index, glomeru-
lar filtration rate [GFR], maximum breathing capacity); other
changes — decreases occur in skeletal muscle mass and total
body water; intracellular water replaced by fat; increased body
fat leads to changes in effects of lipid-soluble drugs and vol-
ume of distribution
Deterioration of organ systems: skin and eyes — skin becomes
thin and fragile, with increased incidence of skin cancers;
gum lines recede; eyes develop cataracts, glaucoma, and
macular degeneration
Cardiovascular: changes include decreases in resting heart rate,
variability in heart rate, and maximum heart rate during exer-
cise; intrinsic rate of sinus node decreases; decreased compli-
ance of ventricles and of vasculature; myofibril dysfunction;
decreases in output of catecholamines; increased thickness
of left ventricle; thickening of valves; circulation time slows,
and dramatically prolonged in elderly patients; conduction
system of heart begins to die, and by age 75 yr only ≈10% of
cells of sinoatrial node still alive; heart becomes less recep-
tive to stimulants of heart rate; young individuals respond
vigorously to isoproterenol and epinephrine, but in aging
patients maximal heart rates not as high; concentration of
beta-receptors markedly reduced
Pulmonary: patients in 70s and 80s have 5-fold to 6-fold
increase in postoperative pulmonary complications (eg,
pneumonia, hypoxemia, hypercarbia, dependence on ventila-
tor); respiratory complications one of leading causes of death
in patients >60 yr of age; decreases in total lung capacity and
maximum ventilation volume; increases in ventilation/perfu-
sion mismatch (increased dead space and shunting); when
young individual given hypoxic or hypercarbic stimulus (eg,
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support,
Audio Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within
the past 12 months that might create any personal conflicts of
interest. Any identified conflicts were resolved to ensure that
this educational activity promotes quality in health care and
not a proprietary business or commercial interest. For this pro-
gram, members of the faculty and planning committee reported
nothing to disclose.
 AUDIO DIGEST ANESTHESIOLOGY 58:21
Fio2 18% or CO2 5% given to breathe), ventilation mark-
edly increases, but same stimuli may not elicit any response
in elderly; decreased function of respiratory musculature;
vital capacity decreases; stiffening of chest wall results in
increased work of breathing at rest; anesthesiologists should
avoid paralyzing and intubating elderly patients; elderly
patients who breathe spontaneously almost always have bet-
ter outcomes
Brain: neurologic disorders account for 50% of incapacita-
tion in elderly (eg, stroke); Alzheimer disease third or fourth
(depending on survey) leading cause of death in United
States; aging causes decreased volume, cell number, activity,
protein synthesis, messenger synthesis, and metabolic rate;
reduced memory and ability to learn; alteration in sleep pat-
terns (contributes to fatigue); decreased motivation and hear-
ing; decreased taste and smell (proposed cause of decreased
appetite); major changes in release of epinephrine and norepi-
nephrine; dysfunction of baroreceptors; hypothermia — risk
dramatically increased; one study demonstrated that when
individuals aged 80 left exposed in standard operating room
for 1 hr, body temperature decreased average of almost 1.5°;
recommended to apply warming devices (eg, Bair Hugger)
in preoperative area to prepare patients for rapid cooling
that occurs in operating room; hypothermia causes increased
bleeding, greater need for transfusions, decreased immune
function, increased vasoconstriction and blood pressure, and
higher risk for myocardial ischemia; these factors may affect
rates of recurrence of cancer
Hormonal changes: elderly have decreased secretion of estro-
gens, testosterone, growth hormone, and cortisol; glucose
tolerance test abnormal in one-third to one-half of patients at
age 65; while glucose may be only slightly elevated (not high
enough to treat), elderly patients do not metabolize glucose
or provide energy as efficiently; diabetes present in 27% of
patients >65 yr of age
Kidney: decreased GFR; reduced ability to concentrate urine;
diminished reserve of renal function; however, no statisti-
cally significant change in serum creatinine until ≥90 yr of
age; majority of patients >80 yr have only one-third of nor-
mal creatinine clearance; creatinine not elevated because of
decreased muscle mass
Hematology: decreased marrow function; loss of suppres-
sive cytokines microenvironment, which results in reduced
immunocompetence and immunosurveillance (likely leading
cause of increased incidence of cancer in elderly); leuko-
penia may occur, with susceptibility to infectious diseases;
platelets remain active, which predisposes person to strokes
(thrombosis on atherosclerotic plaques)
Liver: hepatic mass decreases 40% by age 80; many drugs
metabolized by liver; anesthesiologists must be aware that
patients >65 yr of age have impaired metabolism of almost
all drugs used in anesthesia; Food and Drug Administra-
tion (FDA) requires that all manufacturers perform specific
pharmacokinetic and pharmacodynamic studies on elderly
patients to determine adjustments of doses
Other systems: reduction in size of microvilli of gut results
in decreased absorption of drugs; nervous system — motor
endplates flatten; concentration of acetylcholine receptors
reduced; release of acetylcholine diminished
Anesthetic considerations: half-life of drugs starts increasing at
age 20 to 30; clearance of drugs starts to decline by age 50;
pharmacokinetics — in elderly patients half-life of fentanyl
almost 3 times higher, and midazolam 2 times higher, com-
pared with young patients; requirements for minimum alveolar
concentration (MAC) decline; changes in MAC-awake prob-
ably more important; elderly patients may not wake up with
exhaled concentration of sevoflurane of 0.4; may need to
reduce concentration to 0.1 for patient to awaken
Perioperative plan: American College of Surgeons’ National
Surgical Quality Improvement Program (NSQIP)/American
Geriatrics Society Best Practice Guidelines (2012) gold stan-
dard for optimal preoperative and perioperative management
of geriatric patients; anesthesia plan — minimize routine use
of benzodiazepines; speaker administers benzodiazepine to
65-yr-old patient only upon request or for patient with extreme
anxiety; usually not given for 75-yr-old patient; propofol 10
mg better choice for premedication; must wait longer to see
effects of propofol; desflurane preferred over sevoflurane, and
both preferred over isoflurane; avoid neuromuscular blocking
agents if possible; when neuromuscular agents used, half of
normal dose usually sufficient (but must wait 3 times longer to
see effects); time of onset of rocuronium given at standard dose
(0.6 mg/kg) in younger healthy patient ≈2 min; time of onset in
elderly patients 5 min; opioids characterized by prolonged half-
life and prolonged dynamic effect; forced oral fluid intake and
early ambulation recommended postoperatively; NSQIP guide-
lines suggest ordering “nothing by mouth” (ie, clear liquids)
restrictions for only 2 hr preoperatively; cardiac preload should
be maximized because elderly patients with noncompliant left
ventricle dependent on adequate preload; difference of 100 mL
in intravascular volume may result in difference of systolic
blood pressure between 90 and 120 mm Hg; other consider-
ations — regional blocks should be considered more frequently
in order to avoid use of opioids and other analgesics; every
elderly patient should receive reversal agent; close monitor-
ing in postanesthesia care unit (PACU) warranted if concerned
about adequacy of reversal of muscle relaxants (reversal agents
shorter acting than rocuronium)
Postoperative cognitive dysfunction (PCD): extremely com-
mon; PCD lasting 1 wk occurs in 26% of elderly patients, and
in 10% may persist for 1 mo; leads to prolonged morbidity,
hospital stay, and PACU stay; data show no correlation with
general anesthesia vs regional anesthesia (especially if sedative
hypnotics also given); best meta-analysis (Moyce et al, 2014)
demonstrated that light anesthesia better than deep anesthesia;
inhalation anesthetic yields similar outcomes compared with
total intravenous anesthesia; inhalation anesthesia good choice
for most elderly patients; anesthesiologist should give anes-
thetic that he or she prefers; haloperidol (Haldol) — useful for
confusion and combativeness during emergence and for known
neural dysfunction and Alzheimer disease; data do not sup-
port use for routine prophylaxis, but do support use for rescue
from confusion and combativeness in PACU, and preferred to
administration of analgesics
Use of propofol: to achieve target-controlled infusion level need
to give 30% to 50% less for patients >65 yr of age; takes much
longer to see nadir of blood pressure; peak effect of propofol in
elderly only occurs at ≈10 min
Recovery from anesthesia: use of desflurane results in sig-
nificantly shorter recovery (as measured by, eg, eye opening,
squeezing finger, and time to extubation) compared with sevo-
flurane (experienced clinicians can achieve similar effects with
sevoflurane; however, more challenging for operations >2-3 hr,
patients with obesity, and laparoscopic procedures); advised to
incorporate use of desflurane into clinical practice, especially
for elderly patients; Mayo Clinic (Rochester) had removed
desflurane because of increased cost; however, after observ-
ing delayed emergences from anesthesia and increased hospi-
tal stays, returned to desflurane as standard inhalation agent;
slower wakening correlated with adverse outcomes; Parr et
al (1999) demonstrated that patients barely responsive to ver-
bal stimuli have 6% incidence of respiratory complications
(eg, hypoxia); incidence of adverse events higher in geriatric
patients; elderly patients much more sensitive to benzodiaz-
epines and opioids; both classes have longer half-lives and
should be avoided; muscle relaxant agents — succinylcholine
has lower rate of hydrolysis in elderly patients; time of onset of
succinylcholine, vecuronium, and rocuronium longer; recom-
mended to administer one-half to one-third of standard doses
of sedative hypnotics, opioids, and muscle relaxants
 AUDIO DIGEST ANESTHESIOLOGY 58:21
Conclusions: geriatric patients should be viewed as distinct
and different group (analogous to pediatric patients); take
time during induction; minimize dosing of propofol; use
combination of medications; administer “stunning” dose of
propofol followed by assisted ventilation, or maintain spon-
taneous ventilation; utilize laryngeal-mask airway (LMA);
minimize use of opioids and administer only when definitely
needed; avoid overdose of muscle relaxants because rever-
sal can be difficult; use LMA whenever possible; consider
LMA for procedures in sitting position (eg, surgery of shoul-
der) rather than intubation and paralysis; keep patient warm
and covered; blood pressure and heart rate not predictive of
cardiac function in geriatric patients; blood pressure variable;
encourage patients to move and get out of bed in postopera-
tive period; other agents — according to FDA, scopolamine
patches should not be used in patients >65 yr of age; speaker
agrees with this recommendation unless patient has used them
before; should not be used in patients ≥75 yr because of much
higher incidence of side effects; if scopolamine used, should
be applied only for 6 hr; ketamine may be used in low doses
with no or low-dose opioids
Acknowledgments
Dr. Leslie was recorded at the Scottsdale Anesthesia Conference, presented by Holiday Seminars and held on October 10-16, 2015, in
Scottsdale, AZ. For information on upcoming CME activities from Holiday Seminars, please visit HolidaySeminars.com. The Audio
Digest Foundation thanks the speakers and the sponsor for their cooperation in the production of this program.
Accreditation: The Audio Digest Foundation is accredited by the Accredi-
tation Council for Continuing Medical Education to provide continuing
medical education for physicians.
Designation: The Audio Digest Foundation designates this enduring
material for a maximum of 2 AMA PRA Category 1 Credits™. Physicians
should claim only the credit commensurate with the extent of their partici-
pation in the activity.
The American Academy of Physician Assistants (AAPA) accepts certifi-
cates of participation for educational activities designated for AMA PRA
Category 1 Credit™ from organizations accredited by ACCME or a recog-
nized state medical society. Physician assistants may receive a maximum
of 2 AAPA Category 1 CME credits for each Audio Digest activity com-
pleted successfully.
Audio Digest Foundation is accredited as a provider of continuing nurs-
ing education by the American Nurses Credentialing Center’s (ANCC’s)
Commission on Accreditation. Audio Digest designates each activity for
2.0 CE contact hours.
Audio Digest Foundation is approved as a provider of nurse practitioner
continuing education by the American Academy of Nurse Practitioners
(AANP Approved Provider number 030904). Audio Digest designates each
activity for 2.0 CE contact hours, including 0.5 pharmacology CE contact
hours.
Suggested Reading
Chutka DS et al: Symposium on geriatrics — Part I: Drug prescribing for
elderly patients. Mayo Clin Proc 1995 Jul;70(7):685-93; Chow WB et al:
Optimal preoperative assessment of the geriatric surgical patient: a best prac-
tices guideline from the American College of Surgeons National Surgical
Quality Improvement Program and the American Geriatrics Society. J Am
Coll Surg 2012 Oct;215(4):453-66; Heavner JE et al: Recovery of elderly
patients from two or more hours of desflurane or sevoflurane anaesthesia.
Br J Anaesth 2003 Oct;91(4):502-6; Katoh T et al: Influence of age on
awakening concentrations of sevoflurane and isoflurane. Anesth Analg 1993
Feb;76(2):348-52; Kazama T et al: Comparison of the effect-site k(eO)s of
propofol for blood pressure and EEG bispectral index in elderly and younger
patients. Anesthesiology 1999 Jun;90(6):1517-27; Koscielniak-Nielsen ZJ
et al: Onset of maximum neuromuscular block following succinylcholine
or vecuronium in four age groups. Anesthesiology 1993 Aug;79(2):229-
34; Moyce Z et al: The efficacy of peri-operative interventions to decrease
postoperative delirium in non-cardiac surgery: a systematic review and
meta-analysis. Anaesthesia 2014 Mar;69(3):259-69; Parr SM et al: Level
of consciousness on arrival in the recovery room and the development of
early respiratory morbidity. Anaesth Intensive Care 1991 Aug;19(3):369-72;
Rivera R , Antognini JF: Perioperative drug therapy in elderly patients.
Anesthesiology 2009 May;110(5):1176-81; Woodhouse KW: Pharmacoki-
netics of drugs in the elderly. J R Soc Med 1994;87 Suppl 23:2-4.
The California State Board of Registered Nursing (CA BRN) accepts
courses provided for AMA category 1 credit as meeting the continuing
education requirements for license renewal.
Expiration: The CME activity qualifies for Category 1 credit for 3 years
from the date of publication.
Cultural and linguistic resources: In compliance with California Assembly Bill
1195, Audio Digest Foundation offers selected cultural and linguistic resources
on its website. Please visit this site: www.audiodigest.org/CLCresources.
Estimated time to complete the educational process:
Review Educational Objectives on page 1 5 minutes
Take pretest 10 minutes
Listen to audio program 60 minutes
Review written summary and suggested readings 35 minutes
Take posttest 10 minutes
 AUDIO DIGEST ANESTHESIOLOGY 58:21
ANESTHETIC CONSIDERATIONS IN THE GERIATRIC PATIENT
To test online, go to www.audiodigest.org and sign in to online services.
To submit a test form by mail or fax, complete Pretest section before listening and Posttest section after listening.
1. The incidence of malnourishment in the elderly is:
(A) 5% (B) 10% (C) 20% (D) 40% **

2. Patients in their late 90s who undergo any major surgery have a 30-day mortality risk of:
(A) 20% (B) 35% (C) 50% (D) >60% **

3. There is no statistical change in which of the following until a person is ≥90 yr of age?
(A) Glomerular filtration rate (C) Serum creatinine **
(B) Ability to concentrate urine (D) Creatinine clearance

4. The half-life of midazolam is _______ times higher in elderly patients compared with young patients.
(A) 1.5 (B) 2 ** (C) 3 (D) 4

5. Which of the following is a recommended agent for premedication in geriatric patients?

(A) Benzodiazepine (C) Propofol **
(B) Opioid (D) Premedication not recommended

6. Which of the following is the preferred inhalation agent for elderly patients?
(A) Desflurane ** (B) Sevoflurane (C) Isoflurane (D) Nitrous oxide

7. The time of onset of rocuronium in elderly patients is:

(A) 2 min (B) 3 min (C) 5 min ** (D) 7 min

8. Which of the following approaches is most appropriate for avoiding postoperative cognitive dysfunction in
the elderly patient?
(A) Light anesthesia is preferred to deep anesthesia **
(B) Regional anesthesia is preferred to general anesthesia
(C) Total intravenous anesthesia is preferred to inhalation anesthesia
(D) None of the above

9. Administration of which of the following is recommended in an elderly patient who is confused and combative in
the postanesthesia care unit or has known neural dysfunction?
(A) Midazolam (B) Fentanyl (C) Ketorolac (D) Haloperidol **

10. In geriatric patients, the peak effect of propofol is seen after:

(A) ≈2 min (B) ≈4 min (C) ≈7 min (D) ≈10 min **

Answers to Audio Digest Anesthesia Volume 58, Issue 19: 1-C, 2-D, 3-D, 4-B, 5-D, 6-A, 7-A, 8-B, 9-C, 10-D

!" 2016 Audio Digest Foundation • ISSN 0271-1265 • www.audiodigest.org

Toll-Free Service Within the U.S. and Canada: 1-800-423-2308 • Service Outside the U.S. and Canada: 1-818-240-7500
Remarks represent viewpoints of the speakers, not necessarily those of the Audio Digest Foundation.

View publication stats