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Anesthesia for the

Geriatric Patient
Hasanul Arifin,

Departement of Anesthesiology and Reanimation


Medical Faculty Sumatera Utara University,
H.Adam Malik General Hospital
Medan, Indonesia
2003

I. Concept of Aging and Geriatrics


a. No concensus as to when the geriatric
(elderly) years begin.
Nevertheless, elderly 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

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At a cellular level,
(within mitochondria)

DECREASED
ANTIOXIDANT &
SCAVENGING
CAPACITY

OXIDATIVE
STRESS

CYLE OF
AGING

INCREASED
PROBABILITY
OF DEATH
INCREASED
INTRACELLULAR
FREE-RADICALS

INCREASED
SUSCEPTIBILITY TO
DISEASE, INFECTION
AND INJURY

LOSS OF
TISSUE AND
ORGAN
FUNCTIONAL
RESERVE

DAMAGE TO
MEMBRANES,
PROTEINS, &
GENETIC
INTEGRITY

DECREASED
BIOENERGETIC
CAPACITY

Hand book of Clinical Anesthesia: Barash.PG, Cullen.BF, Stoelting.RK :2001, 64

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II. Aging and Organ Function


A. Function of organ system changing and increasing age
1. Physiologically young elderly patients who
maintain greater than average functional
capacities (maximum organ system function that
is greater than basal demands)
2. Physiologically old 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.

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B. Safety margin 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 increased susceptibility of
elderly patients to stress and disease-induced
organ system decompensation .

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III. Cardiopulmonary function


A.

Cardiac function,
1. The demand for cardiopulmonary function is
maintained in elderly patients by daily exercise.
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)

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5. Age-related diastolic dysfunction elderly


patients more dependent on synchronous atrial
contraction for complete ventricular filling.
a. VR stroke volume compromise
b. Perioperative arterial hypotension is
predictable more common in elderly than in
young.
6. Systolic arterial hypertension fibrotic
replacement of elastic tissue within the
cardivascular system.

B. Repiratory function
Fibrous connective tissue loss of lung elastic recoil
(inevitable emphysema-like changes)
1.
2.
3.
4.

FRC , VC , Residual Volume


Costochondral calcification thorax more rigid WoB
Age related acute postoperative ventilatory failure
Age related decrease in arterial oxygenation
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5. More vulnerable to developing transient apnea when given drug


(opioid, benzodiazepin) post operative.
6. The treshold stimulus needed for vocal cord closure
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.

Elderly patients exhibit decreased immune responsiveness


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V. METABOLISM, BODY COMPOSITION, AND PHARMACOKINETI


A. Aging in men results in a progressive and generalized loss of
skeletal muscle mass and reciprocal increases in the lipid fraction

kg
80-

MEN
WOMEN

70-

BODY
LIPID

6050-

OTHER
TISSUE

4030-

- 70
- 60
- 50
- 40
- 30

BODY
WATER

20100 -

kg
- 80

- 20
- 10

YOUNG OLDER

-0

YOUNG OLDER

Age related changes in body composition are gender specific. Increases in body fat offset bone loss and
intracellular dehydration in women, whereas in man accelerated loss of skeletal muscle and other
component of lean tissue mass produces contraction of intracellular water and a decrease in total body
weight.
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Hand book of Clinical Anesthesia: Barash.PG, Cullen.BF, Stoelting.RK :2001, 654

1. BMR , heat production


hypothermia

, special risk for intraoperative

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 .
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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.
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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 .

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VII. 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 blockade.
Aging appears to produce little change in adrenergic or muscarinic cholinoceptor activity.
B. Baroreceptors that maintain cardiovascular
homeostasis are progressively impaired.
C. ANS underdamped delayed restabilization
during hemodynamic stress. General anesthesia,
spinal, epidural anesthesia (pharmacologic
sympathectomy) systemic hypotension that is
more severe compared with young adult.
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IX. ANALGESIC AND ANESTHETIC REQUIREMENT


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 clinical duration of action
is prolonged if the elimination of the muscle
relaxant is dependent on hepatic or renal
clearance mechanisms.
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DOXACURIUM
PIPECURONIUM
METOCURINE
CURARE
PANCURONIUM
CISATRACURIUM

RI-OLDER ADULT

VECURONIUM

RI-YOUNGER ADULT

ATRACURIUM
ROCURONIUM
MIVACURIUM
I

20

40

60

80

I
100

RECOVERY INDEX
(T25-T75, minutes)

120

RI : Recovery Index , the time required for spontaneous recovery


from 25% to 75% of the control evoked neuromuscular response.
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Hand book of Clinical Anesthesia: Barash.PG, Cullen.BF, Stoelting.RK :2001

X. PERIOPERATIVE MANAGEMENT
AND
OUTCOME.
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 Diseases

Hypertension

Ischemic Heart Disease

CHF

Peripheral vascular disease

COPD

Renal disease

Diabetes Mellitus

Arthritis

Dementia

Hand book of Clinical Anesthesia: Barash.PG,


Cullen.BF, Stoelting.RK :2001, 659

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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
antihypertensives
antidepressants
anticoagulants
oral hypoglycemics
corticosteroids
beta-blockers
sedatives
Hand book of Clinical Anesthesia: Barash.PG, Cullen.BF, Stoelting.RK :2001, 659
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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
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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, full return of
cognitive function to preoperative levels may
require 5-10 days.
E Physical management in OT & RR, require
. special precautions, gentle and careful
positioning
F. Postoperative bleeding & bacterial infection
more likely compared with young adults
Diastolic dysfunction, ventricular stiffness,
rate of iv.fluid (too fast) may precipitate
pulmonary edema
Untreated pain & related emotional stress
immune responsiveness
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Mr. George Bushed

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