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Anesthesia for the

Geriatric Patient

Dr. ASMIN LUBIS,DAF SpAn KAP KMN

Departement of Anesthesiology and Reanimation


Medical Faculty Sumatera Utara University,
Medan, Indonesia
20011
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 &
OXIDATIVE SCAVENGING
STRESS CAPACITY

“CYLE OF
INCREASED AGING”
PROBABILITY OF
DEATH
INCREASED DAMAGE TO
INTRACELLULAR MEMBRANES,
FREE-RADICALS PROTEINS, &
GENETIC
INTEGRITY

LOSS OF
INCREASED TISSUE AND
SUSCEPTIBILITY TO DECREASED
ORGAN
DISEASE, INFECTION BIOENERGETIC
FUNCTIONAL
AND INJURY CAPACITY
RESERVE

Hand book of Clinical Anesthesia: Barash.PG, Cullen.BF, Stoelting.RK :2001, 649


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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 cardiovascular system.

B. Respiratory function
Fibrous connective tissue  loss of lung elastic recoil
(inevitable emphysema-like changes)
1. FRC , VC , Residual Volume
2. Costochondral calcification  thorax more rigid  WoB
3. Age related  acute postoperative ventilatory failure
4. 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 PHARMACOKINETICS
A. Aging in men results in a progressive and generalized loss of skeletal
muscle mass and reciprocal increases in the lipid fraction

kg kg
MEN
80- - 80
WOMEN
70- - 70
BODY
60- LIPID - 60
50- OTHER
- 50
TISSUE
40- - 40
30- - 30
BODY
20- WATER
- 20
10- - 10
0 - -0
YOUNG OLDER 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.
Hasanul-2004 Hand book of Clinical Anesthesia: Barash.PG, Cullen.BF, Stoelting.RK :2001, 654
1. BMR , heat production , special risk for intraoperative
hypothermia
• 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  hyperglycemia

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 synthese
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 ß blockade.
• Aging appears to produce little change in α-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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ORANG GILA BERKELAHI
DENGAN ORANG SUMBING
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
RECOVERY INDEX
I I I I I I I
(T25-T75, minutes)
0 20 40 60 80 100 120
RI : Recovery Index , the time required for spontaneous recovery from
25% to 75% of the control evoked neuromuscular response.
Hand book of Clinical Anesthesia: Barash.PG, Cullen.BF, Stoelting.RK :2001, 658
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X. PERIOPERATIVE MANAGEMENT AND
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 Hasanul-2004
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 Hasanul-2004
Mr. George Bushed

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Terima Kasih !