Geriatric Patients: At Glance

Prof. Dr. Nancy Margarita Rehatta, dr, SpAn, KMN, KNA

 Definition of Geriatric Patients

• Geriatric patients are commonly called “Elderly” patients

• WHO → Elderly patients >60 y.o.
• Mostly cut off used for elderly → >65 y.o
• In 2019, number of aged >60 y.o. was 1 billion, this number will
increase over time
World Population Indonesia
Estimation in Growth of the Elderly Population

Improvements
in health care,
nutrition,
education, and
general living
Life Expectancy Elderly Population
standard

• Between 2010 and 2030, as the baby boom generation reach age 65,
anesthesiologist face a variety challenges
• The fastest growing segment of the population is that aged 85 and older
(Akthar and Rosenbaum, 2018)
Survival curve overtime
(Doods et al, 2016)
HASIL PENELITIAN MULTISENTER GERIATRI-KATI
JAN-APRIL 2021

ANESTHESIA- GERIATRIC

N= 2022
• 13 SENTER PENDIDIKAN
ANESTESI
• PENGAMBILAN DATA: 3 BULAN +
1 BULAN FOLLOW UP
PENGAMATAN
 ICU - GERIATRIC
N=862
• 13 SENTER PENDIDIKAN
ANESTESI
• PENGAMBILAN DATA: 3 BULAN +
1 BULAN FOLLOW UP
PENGAMATAN
Aging
• Process of gradual and spontaneous change, resulting in maturation and
decline through late life
• Senescence is the process by which the capacity for growth, function,
and capacity for cell division are lost over time, ultimately leading to
death.
• Aging comprises both a positive component of development (e.g.,
wisdom and experience) along with the negative component of
physiologic and often cognitive decline.
 Aging process as the main issue in treating
geriatric patients in Anesthesia and ICU

• Some of changes (e.g., decrease in muscle mass), occur even in the well-
conditioned, exercising elderly.
• Morbidity, mortality, and recovery times for elderly undergoing surgery are
substantially greater than those for younger patients.
• Age frequently alters the presentation of surgical illness.
• Symptoms of disease may be diminished, ignored, or inappropriately
attributed to old age.
• Obtaining an accurate history can be challenging in the elderly.
It’s about aging…

This diagram shows that maintaining homeostasis is a dynamic process. The

older person uses or consumes physiologic reserves just to maintain
homeostasis, and therefore there are fewer reserves available for meeting new
challenges.
(Sliverstein et al, 2008)
 Cause Of High Incidence
of Morbidity & Mortality in Geriatric

Increased Pre existing Disease

Decreased Physiologic Reserve

Provider Lack of Knowledge

Coexisting Disease

Cardiovascular

Pulmonary

Renal - GIT

Neurologic

Endocrine

Others….
ALTERATION PHYSIOLOGY & CLINICAL IMPLICATION
FOR ANESTHESIA
Medication Management
Discontinue nonessential medications
→ withdrawal, disease worsening,
interactions w/ anesthetic agents

Continue essential medications.

Plan to resumption of outpatient

medications → minimize poly
pharmacy
 PHARMACOLOGY COSIDERATION

Pharmacokinetics
Normogram for minimum alveolar concentration
Rivera R, Antognini JF. Perioperative drug therapy in elderly patients. Anesthesiology. 2009 May;110(5):1176-81. doi:
(MAC) as a function of age
10.1097/ALN.0b013e3181a10207. PMID: 19352149.
 Parameter Change Effect Examples
Absorption No change

First pass metabolism Decreased for high Bioavailability increased Labetalol, metoprolol, nifedipine,
(decreased liver blood flow) extraction drugs for some drugs propranolol, verapamil

Volume of distribution
Age Related Lean body mass Decreased Increased t1/2 of some Diazepam, midazolam
Change in fat-soluble drugs

Total body water Decreased

Pharmacokinetic Fat issue Increased Increased plasma levels of Alcohol, antipyrine
some water-soluble drugs

Plasma protein binding

Albumin Reduced (especially Increased free Phenytoin, warfaain

in chronic illness, or concentrations
no change)

α1-AGP Increased (or no Decreased free Imipramine

change) concentrations (or no
change)

Hepatic metabolism Decreased ( or no Increased t1/2, decreased Fosinopril, imipramine, levodopa,

(decreased hepatic mass) change) clearance (0r no change) lidocaine, morphine, propranolol,
notriptyline, theophylline

Renal excretion Decreased GFR Increased t1/2, decreased ACE inhibitors, amantadine,
Rivera R, Antognini JF. Perioperative drug therapy in clearance chlorpropamide, cimetidine, furosemide,
elderly patients. Anesthesiology. 2009
May;110(5):1176-81. doi:
gentamicin, metformin, procainamide,
10.1097/ALN.0b013e3181a10207. PMID: 19352149. ranitidine
17
Challenges that anesthesiologist may face in
managing Geriatric Patients in Perioperative and ICU

• The approach to and management of surgery and anesthesia in geriatric

patients is different and more complex than in younger patients.
• Medical team should be aware of the nature of aging physiology, the
interaction of these alterations with pathologies, and the likelihood of
multiple diagnoses and polypharmacy.
• In approaching the elderly as patients, the anesthesiologist must
understand that there is tremendous heterogeneity or variability in aging,
both in the body as well as in individual systems.
This model divides preoperative elements into those that are potentially variable and those
that are not amenable to preoperative alteration. An important aspect is managing the
acute event. The combination of these factors determines the functional outcomes of
patients undergoing surgery.
(Sliverstein et al, 2008)
 Health Condition Issues that may faces in
perioperative management

1. The skin and musculoskeletal system can undergo tremendous alterations.

2. Patients frequently consume multiple medications, and many of these
medications have interactions, with drugs used by anesthesiologists.
3. Acquiring information can be challenging and may involve discussion with not
only the patient, but also their immediate caregiver as well as reference to
previous medical records.
4. Hearing loss is a common complaint and should be understood by the
anesthesiologist.
5. Loss of visual acuity is also common in the elderly.
Differences between in managing geriatric patients
and younger patients in Anesthesia

• In communicating with patients and geriatricians, we should

understand that expectations for recovery are frequently different
than in younger patients, marked by issues of maintenance of
function and independence.
• Integrating care across this continuum can be difficult but
invariably improves patient outcomes.
Frailty
• A term frequently applied to elderly patients is “frail”
• One would expect the frail elderly to be at higher risk for
functional decline following surgery.
• Frailty has been described as a form of pre-disability, which is
distinct from functional impairment
• Frailty as a specific measure has not been prospectively
characterized as a preoperative risk factor.
There are a wide array of molecular, disease, physiologic factors that become
dysfunctional and lead to the clinical manifestation of frailty
(Doods et al, 2016)
 Why does anesthesiologist need to pay
attention in caring geriatric patients?

▪ The incidence of complications increased in elderly

▪ Impact of complications on mortality and functional recovery
increased with age
▪ Many systems of the homeostatic mechanisms of concern in the
elderly, e.g., the autonomic nervous system, immune system, or
even thermoregulatory control, remain difficult to assess.
▪ The goals of therapy for a geriatric patient are frequently
motivated by a desire to avoid disability and preserve or improve
functional status.
▪ In preparing a patient for surgery, informing him or her regarding
the prolonged time to recover is extremely important.
▪ Patients who understand that recovery is a long process are less
likely to become discouraged and more likely to continue
prolonged efforts to regain strength and endurance.
The disablement process: main pathway

(Sliverstein et al, 2008)

Conclusion

• The elderly are vulnerable to the stresses of injury, surgery, and

anesthesia, which may profoundly affect their quality of life

• In addition to a focus on senescent physiology of standard organ

systems, proper evaluation in elderly patients requires attention
to areas that are not frequently evaluated in younger patients.
Reference

• Akhtar, S., Rosenbaum, S. 2018. Principles of Geriatric Critical

Care. Cambridge University Press
• Doods, C. Kumar, C.M. Servin F. 2016. Anesthesia for the Elderly
Patient, Second Edition. Oxford University Press
• Silverstein, J.H., Rooke, G.A., McLeskey, C.H. 2008 Geriatric
Anesthesiology, Second Edition. Springer: New York
• Rivera R, Antognini JF. Perioperative drug therapy in elderly
patients. Anesthesiology. 2009 May;110(5):1176-81. doi:
10.1097/ALN.0b013e3181a10207. PMID: 19352149.
Thank You