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)

OXIDATIVE STRESS

DECREASED ANTIOXIDANT & SCAVENGING CAPACITY

INCREASED PROBABILITY OF DEATH INCREASED INTRACELLULAR FREE-RADICALS

CYLE OF AGING
DAMAGE TO MEMBRANES, PROTEINS, & GENETIC INTEGRITY

INCREASED SUSCEPTIBILITY TO DISEASE, INFECTION AND INJURY

LOSS OF TISSUE AND ORGAN FUNCTIONAL RESERVE

DECREASED BIOENERGETIC CAPACITY

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. 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. Aging decreases the inotropic and chronotropic responses to neurally mediated adrenergic stimulation such that maximum heart rate and inotropic response are age limited. Passive ventricular filling, which normally occurs during the early phase of diastole, is decreased in elderly patients (stiffer and less compliant ventricle)

2.

3.

4.

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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 PHARMACOKINETICS 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

706050403020100 YOUNG OLDER

WOMEN
BODY LIPID OTHER TISSUE

kg - 80

- 70
- 60 - 50 - 40 - 30 - 20 - 10 -0

BODY WATER

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 norepinephrine 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
ATRACURIUM ROCURONIUM MIVACURIUM
I 0 I 20 I 40 I 60 I 80 I 100 I 120

RI-YOUNGER ADULT

RECOVERY INDEX (T25-T75, minutes)

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, 658

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-2003

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 Hasanul-2003

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 510 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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