Anesthesia for the older patients

Lecturer: Giorgi Baindurashvili MD

 INTRODUCTION
• Gerontology is the broadest term applied to studies
of aging

• "Geriatrics” - medical subspecialty that focuses upon care of

the elderly patients

Chronological age is not a limitation for surgery

 DEFINITION

• Ageing is a progressive physiological process that is

characterized by degenerative changes in both structure and
function of organ and tissues with consequent loss of functional
reserve of various systems, more importantly with a decrease in
ability to respond to stress and overcome complication.

• Successful ageing -“low probability of disease and disease-

related disability, high cognitive and physical functional
capacity, and active engagement with life”.
CLASSIFICATIO
N
 FUNCTIONAL RESERVE
• The difference between maximal activity and basal level
of function – Organ system functional reserve
• Physiologically Young – Elderly patients who maintain
greater than average functional capacities.
• Physiologically Old– Elderly patients whose organ
function declines at an earlier age than usual or at a more
rapid rate.

• Chronological age and physiological age are different.

Physiological age is determined by disease process that
might accelerate the aging process.
 CARDIOVASCULAR SYSTEM
1. Exercise tolerance - maximum attainable HR, SV and CO are
typically reduced

2. Decreased cardiac output (by 1% per year) and stroke volume

 Unable to increase CO by increasing HR- due to “hyposympathetic

state”
 SV mostly dependent on venous return

3. Decreased beta adrenergic receptor responsiveness

 Reduced response to stimulation at cardiac and end organ level
 Decreased heart rate
 Decreased baroreceptor sensitivity
 CARDIOVASCULAR SYSTEM
4. Conduction abnormality, sick sinus syndrome

5. Age related arteriosclerosis – chronic elevated afterload, LVH

6. Increased activity of sympathetic nervous system

 Increase in the amount of norepinephrine release.
 Increase in SVR (0.5% increase/yr).
 Slightly increased Alpha receptor response.

8. Decreased response to atropine

 Anesthetic implications

Neuraxial blockade

• Greater degree of stability over GA .

• Eliminates surgical stimulation induced increased sympathetic
tone
• Can cause severe hypotension when compared to GA
• Hypotension- fluid resuscitation and α agonist (in place of α/β
agonist) - restores BP and CO to basal levels
 Anesthetic
implications
General Anesthesia

• Diminished cardiac reserve- exaggerated fall in BP during

induction.
• β blockers promotes hemodynamic stability particularly at
the time of intubation.
• Anticholinergic mixed with α /β agonist are indicated in
bradycardia compromising cardiac output
 RESPIRATORY SYSTEM
Chest wall compliance, the elastic recoil of the lungs and
respiratory muscle strength all decrease.

1. Structural changes
Upper airway- protective reflexes mucociliary function
Lungs
• Tissue elasticity
• Loss of alveolar septa- diffusing capacity physiological dead
space
• Interstitial connective tissue causes duct ectasia - anatomical
dead space.
Stiff chest wall- work of breathing shortness of breath
 Respiratory System

2. Ventilatory mechanics
• Lungs - emphysematous and complaint
• Mismatch between stiff chest wall and respiratory muscle –
weakness. After 60yrs, FVC by 14- 30ml/yr and FEV1 by
23-32ml/yr .
• Air trapping due to loss of elastic forces- closing capacity ,
RV
3. Control of ventilation and Gas exchange
• Ventilator response to hypercapnia by 40% and hypoxia
by 50%- declining chemoreceptor function
• Respiratory drive
 Anesthetic implications

• Difficult mask ventilation- loss of facial contour, buccal fat,

dentition
• Cervical arthritis- restrict neck movements, more prone to
vertebra-basilar artery insufficiency
• Distorted alveoli impairs gas exchange- blood O2
content falls by 10-15% while CO2 levels remain
unchanged
• Less complaint chest wall- greater risk of peri-op hypoxemia
• ABG- more reliable in assessing respiratory functions
 Anesthetic implications
• Premedication- increases risk of aspiration
• Aspiration prophylaxis- sodium citrate, cimetidine,
metoclopramide
• Increase in MV to achieve normal PaCO2 due to gas exchange
abnormality , which is more in recumbent position and in
respiratory disease.
• Early respiratory mobilization and sitting position in post
operative period improves respiratory mechanics and
oxygenation.
 NERVOUS SYSTEM

1. Brain anatomy
• Neuronal shrinkage and loss.
• Production of neurotransmitters - noradrenaline, serotonin,
acetylcholine and dopamine
• Enlarged ventricles
• Function- decline in cognition, motor, sensory and behavioural
function. Decrease in memory, vision, hearing and vibratory sense
in lower extremity is common.
 NERVOUS SYSTEM

2. Cerebral circulation
• Cerebral autoregulation and CO2 responsiveness –well preserved.
• mass-specific (ml/100g/min) global and regional blood flow.
• Progressive total (ml/min) hemispheric blood flow.
3. Neurophysiology - neuronal activity, brain-spinal cord
neurotransmitter activity.
4. Autonomic system- sympathetic and parasympathetic flow.
Common problems- hypothermia, heat stroke, orthostatic
hypotension, syncope
5. Common pathologies- cerebral atherosclerosis, Parkinson’s
disease, Alzheimer’s disease, delirium, depression, dementia
 Anesthetic
implications

• Increased pain threshold and potency of inhalational agents .

• Increased sensitivity to anesthetic drugs
• Delayed recovery from anesthesia
• Incidence of post-op delirium and in 15-50% POCD (post-op
cognitive dysfunction)
• Decreased requirement of LA for spinal and epidural anesthesia
• Tracheal Extubation only when wide awake.
 Thermoregulatio
n
• Elderly- Frail constitution, reduced metabolic rate, reduced
subcutaneous fat
• Delayed and less vigorous compensatory mechanisms cutaneous
vasoconstriction, shivering etc.

Effects of hypothermia
• CNS depression, depression of ventilator drive – postop somnolence and

hypoxia
• Prolonged drug action
• Accelerates protein catabolism
• Hampers wound healing and surgical recovery, impairs coagulation,
immune dysfunction
 RENAL SYSTEM

• Renal tissue atrophy – decrease of glomeruli and nephrons by 40%

• RBF; GFR (45% by 80yrs) ; Creatinine clearance – decline of
0.75ml/min/yr
• Maintain urine output >0.5ml/kg/hr – 1/5th of total post- op death due
to post-op ARF
• Decline in active tubular secretion and reabsorption of drugs
• Elimination half-life of anesthetic drugs prolonged in elderly
• Estimation of Cr. Clearance- Cockroft & Gault formula to assess excretion
of drug
 Fluid and electrolyte disturbances

• Na+ and water homeostasis, functional hypoaldosteronism

impaired Na+ conservation and K + excretion
• Response to fluid loading and dehydration impaired.
• Loss of water of >2kg is significant
• In water depletion, rapid replacement might result in cerebral
edema. Hence, half deficit infused over 24hrs and rest half over
next 24-48hrs
• Volume overload can occur due to functional impairment of
diluting segment of nephrons
• Decreased acid excretion.
 HEPATOBILIARY SYSTEM

• Hepatic tissue- 40-50% of total hepatic tissue involute by the

age of 80.
• Hepatic blood flow ( falls by 1% per yr. to about 40% beyond
60yrs)
• Ability to handle a glucose load –insulin resistance or
impairment of insulin function.
• Quantitative loss of hepatic tissue affects clearance of anesthetic
drugs.
• Further prolongation of action of anesthetic drugs if primary or
secondary metabolite take the renal route for elimination.
 STATURE AND BODY HABITUS

• Loss of skeletal mass (lean body mass)

• Percentage of body fat
• Osteoporosis- micro architectural deterioration of bone and
decreased bone density
• Osteoarthritis- knees, hips, cervical and lumbosacral spine.
• Cervical osteoarthritis may interfere with visualization of glottis
opening.
• Progressive reduction in height- gradual increasing kyphosis
secondary to vertebral compression fractures
Geriatric syndromes Geriatric Disorders
• Osteoporosis • Constipation
• Osteoarthritis • Delirium
• Alzheimer’s Disease • Insomnia
• Parkinson’s Disease • Decubitus Ulcer
• Dementia
 PHARMACOKINETICS AND PHARMACODYNAMICS

Pharmacokinetics:
• The relationship between drug dose and plasma concentration.
It deals with what body does to the drug and it includes drug
absorption, tissue distribution, metabolism and elimination.

Pharmacodynamics:
• The relationship between concentration and clinical effect. It
explains what a drug does to the body.
 Pharmacokinetics
• Plasma concentration and Vd of a drug are inversely related.
• With age percentage of total body fat
Lipophilic drugs, Vd ; accumulation, prolongation of drug effects
• Impaired hepatic metabolism and renal elimination- clearance
• Increase in the arm-brain circulatory time
• Drug- binding proteins- albumin with age
• Qualitative changes in these proteins alters drug-binding and result
in free fraction in circulation, which affects clearance, Vd and
apparent potency.
 Pharmacodynamics

• Physiological state- cardiac output in elderly Prolongs

circulation time to drug effect when drug given IV

• • Polypharmacy - risk of drug interactions

Factors predisposing elderly patients to adverse drug events

• Multiple comorbidities
• Polypharmacy
• Drug-drug interactions
• Age related reduction in metabolism and elimination
• Increased sensitivity of CNS to side effects of the medications
 Most common surgeries in elderly population

• TURP
• Cataract surgeries
• Hernia repair
• Fracture stabilization
• Oncosurgeries
• THR and TKR
 SELECTION OF ANAESTHESIA

• Depends on the patient’s clinical condition, proposed surgical

procedure
• Skill and experience of the anesthesiologist.

Limit surgical stress

Goals

Maintain Functional
reserve
Aims-
• Safe and smooth anesthesia with good cardiovascular control and quick
emergence with minimal post-op cognitive dysfunction or
complication.
• Stable vital parameters and the patient regain protective physiologic
function as rapidly as possible.
 REGIONAL ANAESTHESIA

• Local infiltration and nerve blocks preferred if patient is cooperative

• Lower subarachnoid block for lower abdominal and perineal surgeries

Advantages
• Lower incidence of PDPH due to closure of intervertebral foramina,
which inhibit the leakage of CSF.
• Decreased stress response to surgical stimulation and blood loss
• Decreased incidence of thromboembolism
• Good post operative analgesia, early ambulation and discharge
• Ensures better recognition of ischemic attack and better assessment of
mental status.
• Less risk of aspiration
 Disadvantages

• Difficulty in controlling the level of block

• Increased sensitivity to local anesthetic
• Limited power of adaptation to vasomotor changes. Wide
fluctuation in hemodynamic status.
• Difficulty in technique due to calcified ligaments and
ankyloses of joints.
• Increased incidence of persistent numbness, nerve palsies,
neuralgia
 GENERAL
ANAESTHESIA
MONITORING
• Basic monitors- Pulse oximetry, NIBP, ECG, ETCO2 , urine output
monitoring, temperature monitoring
• Major procedures- CVP, IABP, TEE, ABG analysis

PREOXYGENATION
• Elderly are more prone to cardiac mishaps from desaturation
• Maximum oxygenation in shortest time – 8 deep breaths of 100% oxygen
within 60s with oxygen flow of10L/min

PREMEDICATION
• Anticholinergic- Inj. Glycopyrrolate – antisialogogue
• Anxiolytics- drugs with minimal and short lived sedative effects must be
used. Short actings BZDs with dose titration.
• Aspiration prophylaxis, preferably RSI to be followed for all patients
• Hypertensive response to intubation should be obtunded especially in
hypertensive patients with
• Lidocaine 1.5mg/kg
• Esmolol 0.3mg/kg IV.
• Alfentanil 5µgm/kg IV.

INDUCTION
• Commonly used- Propofol, thiopentone (5-7mg/kg), etomidate (0.3mg/kg)
• Peak effects of drugs administered is delayed: midazolam- 5min, fentanyl
6-8min, propofol- 10min
• Drug dose calculated according to LBW; Propofol 1-1.5mg/kg, and 0.5-
1mg/kg if opioids supplemented.
• Slow onset of anaesthesia due to sluggish circulation.
• Dose titration- delayed elimination due to retarded metabolism
 Maintenance of Anesthesia

• After induction controlled ventilation with muscle relaxants, N20,

O2 , adequate analgesia
• Cuffed tube in patient – to avoid aspiration
• Short or intermediate acting NMBs, dose calculated according to
LBW
• Atracurium and Cisatracurium are more preferred over
Vecuronium and Rocuronium
• Vecuronium dose reduced by 30%.
• Atracurium dose not affected.
• Monitoring depth of neuromuscular blockade is useful
 Maintenance of Anesthesia

• Two fold prolongation in onset of NM block in elderly patients

due decreased cardiac output, slow muscle blood flow.
• Inhalational agents- MAC of all inhalational agents reduced by 4-
5% per decade after 40yrs of age
• Sevoflurane and desflurane excreted unchanged by lungs
• It is better to maintain sub MAC concentrations of potent
inhalationals with b-blockers to control hypertension rather than
use supra MAC
• Combined epidural and GA reduce MAC by as much as 50%
 Delayed recovery from anesthesia

• Prolonged action of anesthetic

drugs, sedative,
• Narcotics, muscle relaxant.
• Hypoxia or carbon dioxide
retention
• Hypothermia
• Diabetic ketoacidosis or
hypoglycemia
• Anemia or myxedema
• Intra operative hypotension.
• Cerebral hypoxia.
 POST-OP SHIVERING

Increases oxygen consumption by 300 % and metabolic rate by 20-38%.

Causes
• Intraoperative hypothermia.
• Adrenal suppression .
• Decreased sympathetic activity.

Prevention
• Warm IV Fluids
• Heating blankets, Warmed water mattresses ,
• Forced air warming.
 POSTOPERATIVE COMPLICATIONS

Post op cardiovascular Post op respiratory complication

complication

• Myocardial infarction • Ventilatory depression

• Congestive heart failure • Hypoxemia
• Cardiac arrest • Carbon dioxide retention
• Arrhythmias • Aspiration
• Hypotension • Pneumonia
• Atelectasis.
 CNS related complications
Post-op delirium
• Typically presents after 24-72 hrs post operatively
• Prevention- controlling intraoperative use of sedation and adequate
post-op pain relief.

Post-op cognitive dysfunction- post-op memory or thinking impairment

that has been corroborated by neuropsychological testing.

• Multifactorial in origin
• Incidence - fairly equal in regional and general anesthesia. Avoided
by maintaining adequate oxygenation and stable hemodynamic status
intra-op and judicious titration of anesthetics.

• POCD may last upto 5-6 months from surgery.

 POST OP ANALGESIA

Adequate post-op analgesia

• Reduces incidence of cardiorespiratory complication.
• Reduces thromboembolic complications.
• Reduces duration of hospital stay.

Commonly used are

• NSAID
• Opioid
• Patient controlled analgesia
• Epidural opioids, Nerve blocks
 CONCLUSION
• A good understanding of the physiological changes that occurs
in these patients , pharmacokinetics and pharmacodynamic
help in planning of an optimal anesthetic technique for each
elderly patient.

• The effects of ageing on the body are numerous, but the most
important point is to differentiate physiological from
pathological and attain prompt optimization prior to surgery.

• To attain best possible outcome in geriatrics is to have a

multidisciplinary approach with involvement of the surgeons,
physicians, cardiologists and anesthesiologists to anticipate,
identify and treat the patient accordingly.