anaesthesia in elderly patients

1. GUIDED BY: DR.SHEETAL
PRESENTED BY:
DR. NANDINI DESHPANDE

3. Elderly-fastest growing population globally.
India→census registrar general of india
from independence 18 million→78 million
in 2001→150 million in mid century
More than 50% of them require two or more
surgeries in lifetime.

4.  Related directly to stiffening and decreased destensibility of
arterial and cardiac wall.
 Age related changes include:
 1.↑MAP and pulse pressure
 2. ↓cardiac output,SV,EF in response to stress
 3. Calcification of valves(aortic and mitral)→↑risk of CVS
death by 50%
 4.↓in compliance of venous system which hinders
changes in intravascular volumes
 5. Cardiac conduction system →fibrotic changes,making
them more prone for arrythmias
 6. Impairement of diastolic relaxation→diastolic
dysfunction in ageing heart→diastolic heart failure
now referred to as Heart failure with preserved
ejection fraction(HFpEF).SO in patients with clinically
evident heart failure EF is preserved in over half.
7.↓arterial elasticity and peripheral sclerosis
 8. ↑sympathetic nervous system activity
 9. ↓b receptor stimulation

5.  1.ANATOMICAL:
 Loss of muscular pharyngeal support→↓in
function of pharyngeal and laryngeal
function
 Loss of ciliary function
 Barrel chest deformity
 Flattening of diaphgram
 Chostochondral joint calcification making
chest less compliant

6.  2.PHYSIOLOGICAL:
↑incidence of upper airway obstruction→more
prone to have apnea and airway obstruction in
RR
Loss of elastic tissue-more airways collapse
during expiration leading to VP mismatch
Volume of pulmonary vascular bed ↓→↑in
pulmonary vascular resistance by 80%
Impaired response to hypoxia,hypercapnia and
mechanical stress→more sensitive to depressant
effects of opioids and BZDs
Loss of elastic recoil+↓surfactant→increase in
lung compliance
VC ↓ and RV↑
FEV1 decreases by 6-8%/decade
Hypoxic pulmonary vasoconstriction is blunted

7.  At rest elderly have to workharder because
of less compliant chest wall
 Ventilatory response to hypoxemia and
hypercapnia are decrease so ABG monitoring
would be more reliable sign in assesing
respiratory function
 Post op age associated muscular weakness
will reduce their ability to cough forcibly
and remove secretions thus chances of post
op pulmonary complications are high

8. ↑ in threshholds for virtually all forms of perception
i.e vision,hearing,touch,sense of joint
position,peripheral pain due to in
1.reduction in electrical activity
2.attrition of afferent conduction pathway
peripheral nervous system and spinal cord
↑ in number of cholinergic receptors at end plate
and surrounding areas compensate for age related
decline in number and density of motor end plate
units.→doses of competitive blockers is not reduced

9.  ↓sensitivity of baroreceptor→orthostatic
hypotension and syncope
 ↓no of receptors,reduced affinity of agonist
molecules e.g ↓ability of b adrenergic
agonists to enhance velocity and force of
cardiac conduction
 Thermoregulation is affected→↑heat loss
and↓ heat tolerance making them
vulnerable to hypothermia and heat stroke

10. Brain size↓→cerebral blood flow and
oxygen consumption ↓
 Continual loss of neuronal
substance→↓dopamine,norepinephrine,
tyrosine,serotonin →depression,loss of
memory and motor dysfunction

11.  ↓renal mass-↓in glomeruli and nephrons by
40%
 Renal blood flow ↓approx 10% /decade after
40 years→↓GFR
 Serum creatinine level →poor indicator of
GFR
Alterations in response to abnormal
electrolyte concentration→renal capacity to
conserve sodium↓→fluid and electrolyte
status should be carefully monitored
1/5th of geriatricperianesthetic surgical
mortality due to accute renal failure

12.  Characterised by
 gastric acidity
 ↓colon motility and anal
function→constipation
 Fecal impaction,fecal incontinence
HEPATIC SYSTEM:
Liver tissue ↓ by 40%→↓hepatic
function→delayed drug metabolism and
earlier saturation of metabolic pathways

13.  Loss of skeletal muscle(↓in lean body mass)
 ↓TBW due to ↓ in intracellular water
 ↑ in percentage of body fat

14.  Glucose intolerance,decresed thyroxin
production or clearance,decreased
production of renin,aldosterone and
testosterone,and increased plasma conc of
ADH
 Leads to DM,thyroid dysfunction,↓sodium
retention,↑potassium absorption and
osteoporosis

15.  plays a significant part in reducing
postoperative complications
 Detailed medical history, physical
examination, laboratory investigations and
an assessment of surgical risk should be
focussed
 Informed Consent
 History and Nutritional status
 prior medical and surgical conditions
history detailed
medication list →multiple drug therapy.
 Physical Examination:regarding hydration,
nutrition, blood pressure, pulse
irregularities,preoperative mental status

16.  directed towards identifying physiologic
deficits and comorbid conditions that may
increase the chances of postoperative
complications
 Various comorbid conditions that should be
predicted in elderly are as follows:
 1.CVS:
a. Hypertension:1.DBP >110 mm Hg
requires control
b. CHF:1.H/O chronic CHF → established
predictor of adverse
perioperative cardiac events.

17.  C. Arrhythmias:▪ sinus node cells are reduced
▪risk of bradycardia and sick
sinus syndrome
▪AF is too high
 D. Diastolic Dysfunction:
▪ECG findings or ejection
fraction are normal
▪cardiac output does not
increase with stress and CHF
may be precipitated with
atrial

18.  2. Diabetes Mellitus:
 stress of surgery will increase hyperglycemia
 discontinue the oral hypoglycemic regimes during
the preoperative preparation
 start insulin regime
 American Diabetic Association (ADA)
recommends:▪pre prandial blood glucose
levels between 80 – 120 mg/dl,
▪bed time concentration
between 100 – 140 mg/dl and
▪ haemoglobin A1C levels < 7%.

19.  3. Pulmonary disease:
 Patients with active pulmonary disease
(bronchial asthma, COPD) should undergo
vigorous preoperative management and
optimization before subjecting them for
surgery
 Smoking:A/E→▪functional anaemia from
carboxyhemoglobin,
▪ increased airway
complication due to hyper
reactive airway,
▪ bronchospasm,
▪ atelectasis

20.  1.ATYPICAL PRESENTATION OF DISEASE:
▪Not infrequently,accute illness→atypical
presentation. eg,appearance of
pneumonia→uncharacteristic features as
confusion,lethargy and general deterioration of
condition.
 2.POLYPHARMACY:
▪ Occurs in 61% of acutely hospitalised older
patients

21.  3.MALNUTRITION,IMMOBILITY, AND
DEHYDRATION:
▪among accutely hospitalized older patient
prevalence of malnutrition is 52%
 4.CHRONIC PAIN:occurs in 25-50% of
community dwelling older persons

22.  Preoxygenation:
▪desaturation occurs faster in older patients
▪8 deep breaths of 100% oxygen within 60
seconds with an oxygen flow of 10 L/min
 Induction of Anaesthesia:
▪ Use of aspiration prophylaxis and rapid
sequence intubation (RSI)
▪Concurrent use of propofol, midazolam
opioids, increase the depth of anaesthesia
▪Hypotension is very common
▪Peak effects of drugs administered is
delayed:midazolam 5 min, fentanyl 6-8min,

23.  1.THIOPENTONE SODIUM:
 ↓in lean body mass→reduction in vd→high
plasma concentrations→↑sensitivity
 Induction doses about 85% of younger patients
 2.PROPOFOL:
 -smaller central compartment and↓vd
 -reduced clearance→induction dose(1.7mg/kg)
 maintainence dose reduced
by 30-50%

24.  3.BENZODIAZEPINES:
 Midazolam,lorazepam,diazepam have
comparable protein binding and vd
 High clearance of midazolam makes it an
attractive alternative
 4.OPIODS:
 Twice as potent in elderly
 50% reduction in doses
 Shorter acting opiods i.e fentanyl,alfentanil
remifentanyl are better choices

25.  5.MUSCLE RELAXANTS:
 No of Ach receptors at NMJ and their sensitivity
to NDMR not altered. Hence dosage required to
block NMJ is unaltered
 Dereased hepatic and renal blood flow and
function responsible for prolonged action
 6.INHALATIONAL AGENTS:
 (MAC) of all inhalational agents is reduced by
about 4–5% per decade above 40 years of age
 ↓ MAC leads to rapid induction
 Recovery prolonged due to larger vd and ↓hepatic
clearance and↓pulmonary gas exchange

26.  INTRA OP HYPOTHERMIA:
 Elderly→ higher risk of becoming
hypothermic because of anaesthetic induced
altered thermoregulatory mechanisms and
low BMR
 Prepping preoperatively and cleaning
postoperatively with warm solutions, using
warming systems, warming IV fluids, keeping
the environmental temperature warmer,
Covering the patients with blankets before
and after the surgery

27.  Difference in outcome between regional and
general anaesthesia in older patients is not clear
 Yet some specific benefits of regional
anaesthesia may provide some benefits;
 1.affects coagulation system by preventing post
op inhibition of fibrinolysis→↓incidence of DVT
or pulmonary embolism
 2.haemodynamic effects may be associated
with ↓blood loss in lower extremity surgeries
 3.does not necessitate instrumentation of
airway→lowers risk of hypoxaemia
 4.opiate sparing effect

28.  1.FOR NEURAXIAL BLOCKS:
 size of epidural space is reduced
 permeability of dura is increased
 volume of CSF decreased
 narrowing if intervertebral space and
osteophyte growth→decreases
transforaminal escape of local anaesthetics
producing an increased level of block
 onset of analgesia with epidural
anaesthesia is more rapid due to increased
permeability of extraneural tissues to local
anaesthetics

29.  2.FOR LOCAL ANAESTHESIA/PERIPHERAL
NERVE BLOCKS:
 decrease in conduction velocity of
peripheral nervesdue todecrease in inter
schwann distance
 decreased no of axons in peripheral
nerves

30.  1.OXYGENATION:
 Increase in CO and ventilation to satisfy O2 demands
does not occur readily
 Diffusion hypoxia may be more prolonged and
serious
 2.POSTOPERATIVE ANALGESIA:
 Poor pain control can lead to slow recovery and life
threatning complications
 Pain →risk factor for POCD
 NASAIDs and paracetamol by iv,im,oralor rectal
routes.but should be avoided in >70 years of
age,renal dysfunction,suffered hymodynamic
instability.
 Peripheral blocks when feasible shouldbe used

31.  3.HAEMODYNAMICS:
 a.HR→may not be a reliable indicator ofhypovolemia
in elderly
 due to reduced no of adrenergic
receptors,decreased efficacy ofbaroreceptor reflexes
and administration of concomitant b-blockers
hypotension may exist without tachycardia.
 b.HYPOTENSION→safer to administer volume in small
intermittent boluses watching response of CVP,BP
and urine output
 c.administration of hypotonic fluids(5%dextrose etc)
may result in hyponatraemia and low serum
osmolalilty resulting in cerebral oedema
 d.ARRYTHMIAS:may represent disturbances due to
pre existing cardiac
disease,hypokalemia,hypomagnesemia,hypocalcemia,
hypoxiaor hypercarbia.
 may indicate MI(esp.
VPCs>5/min,bigeminy,ventricular tachycardia,heart
blocks other than first degree)

32.  4.HYPOTHERMIA:
 Manifests as altered mental status
 delayed recovery from
 anaesthesia
 sluggish DTRs
 slow respiratory pattern
 Leads to metabolic disturbances
 ↓liver and kidney perfusion
 induce coagulopathy
 Management:mild→warming with blankets
 and warm rooms
 severe:active warming methods such as use
of warm iv fluids and surface warming with continuous
core temperature monitoring

33.  Post-Operative Delirium (POD) •
 DSM-MS IV: A change in mental status,
characterized by: –
 a prominent disturbance of attention and
reduced clarity of awareness of the
environment;
 an acute onset, developing within hours to
days, and tends to fluctuate during the
course of the day.

34.  Main clinical features
 • Acute onset
 • Fluctuating course
 • Inattention
 • Disorganized thinking
 • Alteration in consciousness
 • Cognitive deficit (memory, orientation,
executive functions)
 • Hallucinations
 • Psychomotor disturbances
 • Lethargy (hypoactive delirium)

35.  Postoperative Cognitive Dysfunction (POCD)
 • Deterioration of intellectual function
presenting as impaired memory or
concentration.
 • Not detected until days or weeks after
anesthesia
 • Duration of several weeks to permanent
 • Diagnosis is only warranted if:
 – corroborated with neuropsychological
testing
 – evidence of greater memory loss than one
would expect due to normal aging

36.  • POCD
 – Common in all age groups at hospital
discharge (33- 44%)
 – 3 months after surgery the POC incidence
was:
 • 4-5% in those younger than 65
 • 13% in adults older than 60 years
particularly on those with lower educational
achievement
• Associated with increased one-year
mortality