Anesthesia for the

Geriatrics
By
Ahmed El-Shaer
MSc, MD anesthesia, MSc Pain
Management
 Objectives
1- Define the geriatric population
2- enumerate the anesthetic problems
for a Ger. Pt.
3- mention the different methods for
avoiding these problems
4- Categorize patients according to risk
5- Mention the ethical considerations for
dealing with the old aged pts
 The elderly (65 yr) population is the
fastest growing part of the
population in many parts of the
developed world.

Perioperative morbidity becomes

more frequent in the elderly with
steep increases after the age of 75.
 Aging is a universal and progressive
physiological phenomenon clinically
characterized by degenerative
changes in both the structure and
the functional capacity of organs and
tissues.

Aging increases the probability of a

person to undergo surgery.
 Physiology and
pathophysiology of
aging
 Age alters both pharmacokinetic
and pharmacodynamic aspects of
anesthetic management.

The functional capacity of organs

declines and co-existing diseases
further contribute to this decline.
 Cardiovascular
Geriatric patient means:
decreased beta-adrenergic responsiveness
increased incidence of
conduction abnormalities, bradyarrythmias
& HTN.

Fibrotic infiltration of cardiac conduction

pathways conduction delay &
atrial and ventricular ectopics.
increased reliance on Frank-Starling
mechanism for cardiac output.
 It is important to consider fluid
administration carefully:
non compliant older heart (diastolic
dysfunction) + decreased vascular
compliance small changes in
venous return will large
changes in ventricular preload and
cardiac output
elderly patient compensates
poorly for hypovolemia &
exaggerated transfusion.
Cardiovascular effects of aging
 Respiratory
COPD, pneumonia, sleep apnea
very common.
Closing volume increases with age
FEV1 declines 8-10% per decade due
to reduced pulmonary compliance.
PaO2 progressively with age d.t.
V/Q mismatch
anatomical shunt.
Respiratory effects of aging
 Thus, it is recommended that elderly
patients are transferred to PACU with
oxygen via nasal cannula.
Postoperative respiratory
complications are most common in
geriatric patients.
The most significant clinical predictor
of adverse pulmonary outcome is the
site of surgery, with thoracic and
upper abdominal surgery having the
highest pulmonary complication rate.
 Renal function
Renal BF and nephron mass with age
increased risk of acute renal failure in
the postoperative period.

Serum creat. remains stable due to a

reduction in muscle mass(!).

Impairment of sodium handling, conc.

ability and diluting capacity
predisposes elderly pts to dehydration
and fluid overload.
 Nervous system

As the nervous system is the

target for virtually every
anesthetic drug, age related
changes in nervous system
function have essential
implications for anesthetic
management.
 Nervous system
Aging results in decreased
nervous tissue mass
neuronal density
concentration of neurotransmitters
norepinephrine and dopamine
receptors.
 Nervous system
Thats Why:
Dosage requirements for local and
general anesthetics are reduced.

Administration of a given volume of

epidural anesthetic results in
more cephalic spread,
though a shorter duration of sensory
and motor block.
 Nervous system
Elderly patients:
take more time to recover from GA
especially if they were disoriented
preoperatively.
experience varying degrees of delirium.
sensitive to centrally acting
anticholinergic agents.
The % of delirium is less with regional
anesthesia, provided there is no
additional sedation.
Pharmacology
 The circulating level of albumin
(binding protein for acidic drugs)
decreases with age.

While the level of -1 acid

glycoprotein (binding protein for
basic drugs) increases.
 The decrease in total body water leads
to a reduction in the central
compartment and increased serum
concentrations after a bolus
administration of a drug.
On the other hand, the increase in body
fat results in a greater volume of
distribution, thus prolonging drug action.
Drug metabolism could probably be
altered by the aging effect on hepatic or
renal function.
TO SUM-UP

The elderly are more sensitive to

anesthetic agents and generally
require smaller doses for the
same clinical effect, and drug
action is usually prolonged.
anesthetic agents in the elderly
Inhalation drugs:
Minimum alveolar anesthetic
conc. (MAC) decreases
approximately 6% for every
decade.
Due TO
altered activity of neuronal ion channels
associated with cholinergic, nicotinic and
GABA receptors.

Alterations in ion channels, synaptic activity

and receptor sensitivity.
Opioids:
The elderly require less doses for pain
relief.
Morphine clearance is decreased.
Sufentanil, alfentanil, and fentanyl are
twice as potent in the elderly, d.t.
increased brain sensitivity.
Remifentanil is more potent in geriatric
pts.
For All: infusion rates should be
titrated.
Neuromuscular blockers:

The duration of drug action may be

prolonged if their metabolism
depends on renal or hepatic
excretion.

Cisatracurium undergoes Hofmann

degradation ,so, unaffected by age.
Peripheral nerve blocks:
The duration of analgesia may be
prolonged with age depending on the
baricity of the bupivacaine solution.

When using 0.75% ropivacaine for

nerve blocks, age is a major factor in
determining the duration of motor and
sensory block.

When GA carries great risk for the pt,

regional anesthesia could provide an
excellent solution.
Preoperative evaluation
 it is very important to determine the
patients status and physiologic reserve
in the pre-anesthetic evaluation.

The risk from anesthesia is more

related with the presence of co-existing
disease than with the age of the
patient.

If the condition can be optimized

before surgery this should be done
without delay, as long delays increase
morbidity rates.
 DM and CV diseases are very common.

Pulmonary complications are one of the

leading causes of postoperative
morbidity, so, pulmonary optimization
is essential.

History, physical examination, Lab. and

diagnostic studies are of great
importance.
 Some more issues that must be
always in mind in a geriatric
patient is the significant
possibility of depression,
malnutrition, immobility and
dehydration.
 It is important to determine the
cognitive status of an elderly patient.

Cognitive deficits are associated with

poor outcomes and higher
perioperative morbidity.

It is controversial whether general

anesthesia accelerates the
progression of senile dementia.
 lower doses of premeds.
Opioid premed is valuable only if there is
severe preoperative pain.
Anticholinergics are not required since
salivary gland atrophy is usually present.
H2 antagonists are useful to reduce the
risk of aspiration.
Metoclopramide could be used to
promote gastric emptying, although risk
of extrapyramidal effects is higher.
Intraoperative care and
anesthetic management
 Advanced age is not a contradiction for
either GA or RA.
Some aspects of RA may benefit the pt.:
It prevents postoperative inhibition of
fibrinolysis decreases the incidence
of DVT after total hip arthroplasty.
The hemodynamic effects of RA may
reduce blood loss in pelvic and lower
extremity operations.
More important, the patient maintains
his airway and pulmonary function.
 Advanced age and general
anesthesia are associated with
hypothermia, so; Maintenance of
normothermia is important as
hypothermia to myocardial
ischemia & hypoxemia in the early
postop. period.

In case of general anesthesia, it is of

major importance to titrate drug
doses and it would be wise to use
short acting drugs.
 The use of peripheral blocks
promises favorable outcomes
without compromising airway or
hemodynamics.

However, peripheral blocks have

shown to last longer d.t. some
anatomic changes in geriatric
patients.
Postoperative care
 Pulmonary problems are of major
importance in the postoperative
period.

Shorter hospitalization is badly

needed.

Minimal-invasion surgery and

regional over general anesthesia
when possible, could probably lead
to a more favorable outcome for
geriatric patients
 Common causes of postoperative
morbidity:

Atelectasis
Heart failure
Pneumonia
Delirium
Neurological disease
Acute bronchitis
Myocardial infraction
Postoperative delirium
 Postoperative delirium is common in
the elderly in the postoperative period.
It can result in increased morbidity,
delayed functional recovery, and
prolonged hospital stay.
In surgical patients, factors such as
age, alcohol abuse, low baseline
cognition, severe metabolic
derangement, hypoxia, hypotension,
postop. Pain and type of surgery
appear to contribute to postoperative
delirium.
 Anesthetics, esp. anticholinergics
and benzodiazepines, increase the
risk for delirium.
Despite the above
recommendations, postoperative
delirium in the elderly is poorly
understood.
Research is needed to define the
effects of hypoxemia on cerebral
function and whether oxygen
therapy has any benefits.
The geriatric-anesthesiologic
intervention
program:
pre- and postop. geriatric assessment,
early surgery,
thrombosis prophylaxis,
oxygen therapy,
prevention and treatment of
perioperative decrease in BP, and
vigorous ttt of any postoperative
complic.
In Conclusion
 Elderly patients are uniquely vulnerable
and particularly sensitive to the stress of
trauma, hospitalization, surgery and
anesthesia.
Accordingly, minimizing perioperative risk
in geriatric patients requires:
meticulous preoperative assessment of
organ function and reserve,
meticulous intraoperative management of
coexisting disorders,
Careful drug selection & dosage titration,
Careful fluid therapy,
RA better than GA
Proper psychological preparation &
management
THANK YOU