Review Article

Procedural sedation analgesia in the elderly patient

ABSTRACT
Elderly patients are perceived as a high‑risk group for procedural sedation. Procedural sedation analgesia (PSA) is generally
safe in older adults. What is not acceptable is undertreating pain or inadequately sedating a stable patient. All the usual
precautions should be taken. One should consider any comorbidities that could make the patient more at risk of adverse
reactions or complications. Older patients may be at higher risk for oxygen desaturation, but they usually respond quickly
to supplemental oxygen. Geriatric patients usually require lower doses of medications. They tend to be more sensitive to
medications, with slower metabolism, less physiologic reserve to handle side effects, and a smaller volume of distribution.
The use of drugs for sedation in elderly patients requires careful consideration of their age‑related changes in physiology
and pharmacokinetics. The choice of drug should be based on the patient’s medical condition, comorbidities, and potential
adverse effects. Moreover, the administration should be done by trained personnel with close monitoring of vital signs and
level of consciousness to prevent complications such as respiratory depression.

Key words: Analgesia, elderly, geriatrics, moderate sedation, PSA

Introduction and cautious administration of sedation will help reduce

the risks associated with sedation in the elderly.[1] With
Procedural sedation analgesia (PSA) can safely be increasing age, the incidence of both benign and malignant
administered to the elderly population. The definition of gastrointestinal (GI) disease rises. Endoscopic procedures are
elderly is a subjective term. That is, each patient should be commonly performed in elderly and very elderly patients to
considered an individual person with different physiologic diagnose and treat GI disorders. There are many issues to
and psychologic needs. Special attention must be given to contemplate when considering performing an endoscopic
ensure a safe environment for the induction of sedation in procedure on an elderly patient, including the anticipated
the elderly patient. The patient should be fully assessed, benefits of endoscopy and the increased risks associated
considering the physiologic changes that accompany with procedural sedation and some endoscopic procedures.[2]
aging. Elderly patients have an increased variability of This review will be in two parts. The first part will be an
drug response and decreased requirements for most overview of PSA, and the second part will focus on the
anesthetic drugs. Elderly patients have an increased redosing pharmacology of the most commonly used drugs in PSA.
interval. Continuous monitoring for signs of intolerance

Access this article online This is an open access journal, and articles are distributed under the
Quick Response Code terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike
Website: 4.0 License, which allows others to remix, tweak, and build upon the
https://journals.lww.com/sjan work non‑commercially, as long as appropriate credit is given and
the new creations are licensed under the identical terms.

For reprints contact: [email protected]

DOI:
10.4103/sja.sja_575_23 How to cite this article: Eldawlatly AA, Delvi MB, Ahmad A. Procedural
sedation analgesia in the elderly patient. Saudi J Anaesth 2023;17:533-9.

Abdelazeem Ali Eldawlatly, Mohamed Bilal Delvi, Abdulaziz Ahmad

Department of Anesthesia, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Address for correspondence: Prof. Abdelazeem Ali Eldawlatly, Department of Anesthesia, College of Medicine, King Saud University,
Riyadh, Saudi Arabia.
E‑mail: [email protected]

Submitted: 27‑Jun‑2023, Revised: 28-Jun-2023, Accepted: 29-Jun-2023, Published: 18-Aug-2023

© 2023 Saudi Journal of Anesthesia | Published by Wolters Kluwer - Medknow 533

 Eldawlatly, et al.: PSA in elderly patients

PSA overview elderly patients. Equally, the summation of different issues

PSA is produced by the administration of pharmacologic of the moderate sedation ladder will help providers not
agents, by a route that results in a depressed level of to miss any step of the moderate sedation protocol. An
consciousness, but allows the patient to independently anesthetist‑led service is ideal but is a scarce resource. Safe
maintain a patent airway and respond appropriately to protocols and sedation guidelines are beyond the scope of
verbal commands or physical stimulus. Sedation occurs on a this review because these have been covered extensively
continuum from minimal sedation to general anesthesia, and elsewhere.[7] Nonetheless, it is mandatory to emphasize
patients progress along that line based on the medication that if anesthetists cannot provide a service, then others
given, the route, the dose, and the patient’s own current will need training, support, and monitoring, ideally from
clinical status. The provider caring for the patient must the local anesthetic department. The Joint Commission
be able to recognize the clinical differences between the on Accreditation of Healthcare Organizations (JCAHO)
levels of sedation and be able to rescue the patient, should recognizes the risks involved with sedation and analgesia
the patient progress to a deeper level than was intended. for procedures and mandates that sedation practices
For example, the healthcare provider who is capable of throughout an institution be monitored and evaluated by
monitoring or administering moderate sedation must be the department of anesthesia. The American Society of
able to recognize when the patient has slipped into deep Anesthesiologists (ASA) has responded to this challenging
sedation and provide any necessary emergency care. This responsibility by developing practice guidelines for
care may include airway support, fluids, more frequent non‑anesthesiologists who provide sedation and analgesia.
assessments, or an immediate consult with an anesthesia Standard monitoring of heart rate, blood pressure, and
provider or other practitioner with advanced airway skills, if arterial oxygen saturation during endoscopy is recommended
necessary. The sedation continuum was first coined in 1985.[3] by current guidelines on procedural sedation. The current
Being a subjective‑based continuum, it has been recently ASA guidelines recommend the use of capnography in any
formulated to include some objective columns to predict patient undergoing moderate sedation. Capnography is
the ongoing risks of serious adverse events.[4] However, an excellent tool for the early detection of hypoxemia and
we sought to modify the current sedation continuum to apnea in patients undergoing sedation for GI endoscopy.[8]
make it more self‑explanatory. Our modification included The Integrated Pulmonary Index® (IPI) is an algorithm using
defining a level that we called the deeper sedation level. parameters measured by capnography, such as partial
Furthermore, we added the drug‑induced raw at the bottom pressure end‑tidal carbon dioxide (PetCO2) and respiratory
of the original table of the sedation continuum. The reason rate, as well as parameters measured by pulse oximetry,
for adding the drug‑induced raw is to bring a close focus to such as heart rate and arterial oxygen saturation (SpO2).
the so‑called endoscopist‑directed propofol practice, which Therefore, it combines the benefits of ventilation monitoring
induces a deep sedation level on the continuum; however, and oxygenation monitoring and could be a simple and handy
with a little increase in the propofol dose the patient can device to monitor patients during sedation. IPI delivers a
easily be introduced to a deeper level on the continuum.[5] score from 1 to 10 that is supposed to help the medical team
We believe that the “modified sedation continuum” adds a evaluate the patient’s respiratory status by looking at a single
new dimension to the paradigm of defining different levels parameter only. Values of 7–10 reflect stable parameters,
of sedation, which indefinitely will help physicians’ providers whereas values below 7 require attention.[9]
to distinguish between deep and deeper sedation levels
and hence interfere timely and properly earlier to rescue There is an increasing number of elderly patients who undergo
the patient before any serious adverse events happen. For diagnostic bronchoscopy and GI endoscopic procedures under
better performance and understanding of the moderate sedation and local anesthesia. Although PSA for endoscopic
sedation protocol, a course using a combination of didactic procedures improves patient comfort, there is a risk of
and simulation education is essential. For this purpose of oversedation in elderly patients. Only a few studies have
course, we sought to develop a road map or what we call evaluated the efficacy and safety of sedation for endoscopic
the “moderate sedation ladder,” which summarizes the procedures in elderly patients. Practitioners providing PSA
four essential steps of moderate sedation practice. The should have a thorough knowledge of the pharmacology of
ladder is similar to the World Health Organization (WHO) the agents used. The potential adverse effects of these agents
analgesic ladder, but with different contents.[6] We believe on airway patency, respiratory function, and hemodynamic
that understanding the modified sedation continuum will balance should be fully appreciated. Adverse events during
enable providers with a clear distinction between different procedural sedation may be prevented by the appropriate
levels of sedation and hence proper titration of the induced pre‑sedation evaluation of the patient, intraprocedural
drugs to avoid serious adverse events with reference to monitoring of physiologic function, and early intervention
534 Saudi Journal of Anesthesia / Volume 17 / Issue 4 / October-December 2023
 Eldawlatly, et al.: PSA in elderly patients

when adverse effects are recognized. In the following section, are commonly performed in elderly patients. With the
we are going to discuss some of the drugs used in PSA that aging of the population and the development of digestive
are suitable for elderly patients. endoscopy technology, the number of elderly patients
undergoing GI endoscopic procedures is increasing year
Drugs used in PSA by year. Although it is a noninvasive procedure, it usually
Given the continued increase in the complexity of invasive causes obvious discomfort in the majority of patients,
and noninvasive procedures, healthcare practitioners are including nausea, vomiting, anxiety, or pain. Procedural
faced with a larger number of patients requiring procedural sedation during GI endoscopy not only alleviates patients’
sedation. Effective sedation and analgesia during procedures anxiety, pain, and discomfort but also provides a comfortable
not only provide relief of suffering, but also frequently environment for endoscopists throughout the procedure.
facilitate the successful and timely completion of the Despite procedural sedation being generally considered safe
procedure. However, any of the agents used for sedation in most patients, elderly patients undergoing procedural
and/or analgesia may result in adverse effects. These adverse sedation are associated with a higher risk of hemodynamic
effects most often affect upper airway patency, ventilatory instability, respiratory depression, and delayed discharge
function, or the cardiovascular system. The pharmacology time, especially in those with cardiopulmonary disease
of the most commonly used agents for PSA and the outlines conditions. Therefore, it is very important for elderly
of their primary effects on respiratory and cardiovascular patients to choose safe and effective anesthetics during
function will be mentioned in this part. Suggested guidelines gastroscopy.[12]
for the avoidance of adverse effects through appropriate
pre‑sedation evaluation, early identification of changes in Benzodiazepines
respiratory and cardiovascular function, and their treatment Benzodiazepines are a class of drugs that act on the central
are outlined. Effective sedation and analgesia during nervous system to produce sedation, anxiolysis, and muscle
procedures not only provide humanitarian relief of suffering, relaxation. They are commonly used in elderly patients due
but also frequently facilitate successful and timely completion to their rapid onset and short duration of action. However,
of the procedure. Adverse effects on hemodynamic benzodiazepines can cause cognitive impairment, confusion,
and/or respiratory function may occur whenever sedative falls, and respiratory depression in elderly population.
and analgesic agents are administered. It is important to Therefore, they should be used with caution and at lower doses
note that no agent is completely devoid of the potential than younger adults. Benzodiazepines bind to receptor sites
for life‑threatening effects on respiratory and hemodynamic in the GABA system, increasing the efficacy of the interaction
function. The occurrence of such problems and their impact between GABA, its receptor, and the chloride channel.
on physiologic function can be lessened by the appropriate Midazolam is the benzodiazepine most frequently used for
pre‑sedation evaluation of patients, the monitoring of procedural sedation. It is a short‑acting, water‑soluble agent,
physiologic functions during sedation, and early intervention which provides reliable anxiolysis, sedation, and amnesia.
should problems arise.[10] The number of noninvasive and Of clinical note, the benzodiazepines as a group provide no
minimally invasive procedures performed outside of the analgesia, and so are often coadministered with opioids,
operating room has grown exponentially over the last several generally fentanyl, because of their similar pharmacokinetic
decades. Sedation, analgesia, or both may be needed for profiles (rapid onset and offset), which are desirable during
many of these interventional or diagnostic procedures. PSA. Benzodiazepine metabolism occurs via hepatic oxidation
Individualized care is important when determining whether a and glucuronidation with the potential prolongation of
patient requires PSA. The patient might need an antianxiety their effects in patients with hepatic dysfunction. Effective
drug, pain medicine, immobilization, simple reassurance, sedation with midazolam can be provided by multiple
or a combination of these interventions. Some procedures routes of administration including oral, intranasal, rectal,
are painful, and others are painless. Therefore, the goals intramuscular, and intravenous delivery. The benzodiazepines
of PSA vary widely. Sedation management can range from can have adverse effects on respiratory and hemodynamic
minimal sedation, to the extent of minimal anesthesia. function. These effects occur in a dose‑dependent fashion and
PSA in the emergency department (ED) usually requires are modified by comorbid diseases and the synergistic effect
combinations of multiple agents to reach the desired effects of coadministration with other sedative or analgesic agents
of analgesia plus anxiolysis. However, moderate sedation, such as opioids. When midazolam is coadministered with an
deep sedation, minimal anesthesia, and conventional opioid, the sedation plan should include titration to effect,
general anesthesia can be all utilized for the management especially in elderly patients beginning with a lower dose of
of GI endoscopy.[11] Many GI endoscopic procedures such as midazolam (0.05 mg/kg). Other clinically significant adverse
diagnostic gastro‑duodenoscopy or screening colonoscopy effects include paradoxical excitement, which may occur in
Saudi Journal of Anesthesia / Volume 17 / Issue 4 / October-December 2023 535
 Eldawlatly, et al.: PSA in elderly patients

up to 10–15% of patients.[13] These effects can be particularly propofol, the incidence of respiratory depression and other
alarming to family members and staff, as they are completely sedation‑related adverse events caused by remimazolam are
opposite in nature to the desired and expected results. significantly lower and it is a suitable alternative sedative
agent for elderly patients undergoing gastroscopy due
In a retrospective study, the records of 210 patients who to its non‑inferior efficacy and higher safety profile.[17] In
underwent diagnostic bronchoscopy were analyzed. PSA another study, it was shown that the rates of hypotension,
was achieved with midazolam sedation at National Hospital bradycardia, and respiratory suppression were lower in
Organization Omuta National Hospital between June 2017 and elderly patients receiving remimazolam versus propofol on
October 2019. Patients were administered 1 mg midazolam a fentanyl background for upper GI endoscopic procedure.[18]
following 10 mL 4% lidocaine inhalation. When sedation was
insufficient, 0.5 mg midazolam was administered additionally. Propofol
Diagnostic yield, incidence of complications, amount of Propofol is a sedative or amnestic agent, possesses no
oxygen supplementation, decreases in percutaneous oxygen analgesic properties, and should be combined with an
saturation (SpO2), changes in blood pressure, and degree opioid or ketamine preferably with ketamine (commonly
of comfort were analyzed. Patients were divided into the known as “ketofol”) when analgesia is required. Ketamine–
elderly (n = 102) and non‑elderly (n = 108) groups. No propofol combination is attractive because of the opposing
significant differences were observed in diagnostic yield hemodynamic and respiratory effects of these two agents. The
and procedure time between the two groups, and no severe anesthetic induction dose of propofol in healthy adults ranges
adverse events were noted in the elderly group. The degree of from 1.5 to 3 mg/kg b.w. with recommended maintenance
comfort during bronchoscopy was significantly higher in the infusion rates varying from 50 to 200 µg/kg/min (3–6 mg/kg/h),
elderly group. In patients administered <2 mg midazolam, depending on the depth of sedation that is required. Following
the amount of oxygen supplementation and decreases in intravenous administration, propofol is rapidly cleared from
SpO2 were significantly smaller in the elderly group compared the central compartment and undergoes hepatic metabolism
with the non‑elderly group. The risk of adverse events related to inactive water‑soluble metabolites, which are then renally
to midazolam sedation in bronchoscopy does not increase cleared. Its rapid redistribution, clearance, and metabolism
with age, and sedation improves comfort during flexible provide rapid awakening when the infusion is discontinued.
bronchoscopy in elderly patients. Moreover, a total dose of Rapid arousal and quick return to baseline behavior allow for
midazolam <2 mg is safe for elderly patients undergoing early discharge following outpatient procedures. Propofol
bronchoscopy. [14] A study has revealed that midazolam slightly affects POCD. It is well established that moderate
administration increases the risk of postoperative cognitive sedation results in a high level of both patient and physician
dysfunction (POCD) in elderly patients.[15] POCD is going to satisfaction and may also improve the quality of upper GI
be discussed in detail in some review articles in this special endoscopy. Data on combined sedation with midazolam or
issue on geriatric anesthesia. propofol for GI endoscopic procedures in elderly patients
are very rare. In a retrospective analysis of midazolam or
Remimazolam propofol sedation during 454 endoscopic procedures in
Remimazolam is a short‑acting benzodiazepine that is 347 patients ≥70 years with high‑level comorbidity reflected
used for sedation and anesthesia. It was developed by by a 28‑day mortality rate of 2.9% and an ASA score of
PAION AG, a German pharmaceutical company, and was class III or higher, the authors found no procedure‑associated
approved for use in Japan in 2019. Remimazolam works by mortality or major side effects. In comparison with patients
enhancing the activity of gamma‑aminobutyric acid (GABA), of younger age, elderly patients needed lower propofol doses
a neurotransmitter that inhibits the activity of neurons in with few minor complications.[19]
the brain. This leads to sedation, relaxation, and reduced
anxiety. Remimazolam undergoes dose‑independent ester Dexmedetomidine
hydrolysis. In the clinical doses, the enzymes are unlikely Dexmedetomidine is an α2 adrenergic agonist with
to be saturated, and as a result, there is no accumulation beneficial sedative properties and a limited adverse effect
reported. In other words, the rate of reaction continues to profile. Dexmedetomidine causes its physiologic effects
follow first‑order kinetics and is unlikely to change to zero by activation of specific transmembrane α2 adrenergic
order in the recommended doses. As a result, increasing receptors at various locations throughout the Central
doses or prolonged infusions are unlikely to have prolonged Nervous System. These effects include sedation, anxiolysis,
or residual effects. Due to organ‑independent elimination, and analgesia. Hypertension has also been reported during
it can be safely used in elderly patients with hepatic or renal the loading dose. This hemodynamic effect is thought
impairment.[16] In one study, it was shown that compared with to be mediated via peripheral α2B adrenergic agonist
536 Saudi Journal of Anesthesia / Volume 17 / Issue 4 / October-December 2023
 Eldawlatly, et al.: PSA in elderly patients

leading to vasoconstriction before the onset of the central Unfortunately, fentanyl possesses respiratory depressant
effects. Bradycardia appears to be more common when effects that may be additive with those of propofol when
dexmedetomidine is coadministered with other medications these agents are used in combination. The elderly patient
that have negative chronotropic effects.[20] Endoscopic requires fewer doses for pain relief. Morphine clearance
retrograde cholangiopancreatography (ERCP) is an advanced is decreased in the elderly patient. Sufentanil, alfentanil,
endoscopic procedure and requires deep sedation. Deep and fentanyl are twice as potent in the elderly patient,
sedation with dexmedetomidine for the respiratory drive due to an increase in brain sensitivity to opioids with
preserved has become popular in recent years. However, the age. There are changes in the pharmacokinetics and
use of dexmedetomidine in elderly patients is controversial pharmacodynamics of remifentanil, which is more potent
because its adverse events are more common. In one study in geriatric patients. Clearance and the volume of the
that investigated the effectiveness of a single loading dose central compartment decrease with age, and the infusion
of dexmedetomidine combined with propofol for deep rates should be titrated.[27] Fentanyl is a short‑acting opioid
sedation of ERCP in elderly patients, it was found that the with high potency and minimal cardiovascular effects. This
combination reduced propofol consumption and artificial agent has a rapid onset of action, usually within 2 minutes,
airway intervention and provided better hemodynamic and the duration of action is 30–40 minutes. The serum
stability than propofol alone for deep sedation in elderly half‑life is approximately 90 minutes. This combination of
patients during ERCP.[21] rapid onset, high potency, and short half‑life makes fentanyl
an excellent agent for most PSA procedures in the ED. The
In one study, it was found that patients who received usual required dose is between 2 and 3 µg/kg by slow IV
dexmedetomidine sedation supplement for peripheral push given in increments of 0.5–1 µg/kg every 2 minutes
nerve block were associated with a lower incidence of to a maximum of 5 µg/kg for both adults and children. The
postoperative delirium (POD) and early POCD compared total amount of the agent required is dependent on the
with propofol sedation. Sedation with dexmedetomidine individual’s response. Because of its high potency, safety,
also facilitated patients to be out of bed and discharged and relatively short half‑life, fentanyl is very easy to titrate
early after surgery.[22] using multiple small doses to achieve the desired effect,
especially in elderly patients. Fentanyl can induce severe
Ketamine respiratory depression, especially when used with other
While ketamine has become a favorite agent in many PSA agents such as midazolam. This side effect is dose‑related
procedures and has been used successfully in children for and usually appears within 5 minutes of administration
many years, it is probably not the best first choice in certain of the agent. The doses used for PSA in the ED have not
older adults. been reported to cause muscular and glottic rigidity or
• There are several older, small studies of ketamine used “board chest,” which has been well documented when
as the sole agent in the OR to perform open reduction the agent is used in anesthetic doses. General pruritus is
and intern fixations of hip fractures in older adults.[23] In usually not present with the use of fentanyl as occurs with
a study with an average patient age of 83 years, during many opioids as it does not cause histamine release, and
ketamine administration, patients experienced increased nausea is usually minimal when compared to other opioid
blood pressure and cardiac index, but there were no analgesics.[28]
serious adverse events.[24] Another small study compared
ketamine and propofol as the sole agents during hip Reversal agents
fracture repair in the operation room and found that Both benzodiazepines and narcotics have reversal agents
ketamine increased myocardial oxygen demand.[25] that if used correctly could save an over‑sedated patient
• In general, there is a higher prevalence of hypertension from having a respiratory arrest. Flumazenil antagonizes the
and coronary artery disease among older patients. action of benzodiazepines on the central nervous system and
Increasing the myocardial oxygen demand could present inhibits activity at GABA or benzodiazepine receptor sites. It
a risk with ketamine use. However, there is little evidence is contraindicated in patients with serious tricyclic overdoses.
that ketofol may be a good option (combination of Available in injectable 0.1 mg/mL, flumazenil can be given
propofol and ketamine), but the recent studies of ketofol undiluted or in 5% dextrose in water, lactated Ringer’s
in the ED enrolled a few older patients.[26] solution, or 0.9% normal saline. The initial dose is 0.2–0.4 mg
IV over 15 seconds. If ineffective, a second dose can be given
Opioids every 60 seconds. The maximum initial dose is 1.0 mg. If
Fentanyl is a rapidly acting opioid (at doses between 1 and the patient becomes over‑sedated, an additional dose can
2 ug ⁄ kg) often coadministered for pain control during PSA. be given and a drip may need to be started because the
Saudi Journal of Anesthesia / Volume 17 / Issue 4 / October-December 2023 537
 Eldawlatly, et al.: PSA in elderly patients

half‑life of the offending benzodiazepine may be longer than References

the half‑life of flumazenil, whose half‑life is 40–80 minutes.
Adverse effects include seizures, dizziness, headache, blurred 1. Homfray G, Palmer A, Grimsmo‑Powney H, Appelboam A, Lloyd G.
Procedural sedation of elderly patients by emergency physicians:
vision, diplopia, visual field deficit, hyperventilation, nausea,
A safety analysis of 740 patients. Brit J Anaesth 2018;121:1236‑41.
and vomiting. 2. Travis AC, Pievsky D, Saltzman JR. Endoscopy in the elderly. Am J
Gastroenterol 2012;107:1494‑502.
Naloxone hydrochloride is a pure narcotic antagonist. 3. Sebastiani F.R , Dym H,Wolf J. Oral sedation in the dental office. Dent
Clin North Am 2016;60:295-307.
It reverses the respiratory depression, sedation, and
4. Green SM, Mason KP. Stratification of sedation risk — A challenge to
hypotensive effects of opioids. In the absence of narcotics, the sedation continuum. Paediatr Anaesth 2011;21:924–3.
naloxone has no activity. Caution needs to be used in 5. Eldawlatly AA. Moderate sedation: Introducing the “modified sedation
narcotic addiction, cardiac disease, and use of cardiotoxic continuum” and the “moderate sedation ladder”. Saudi J Anesth
2014;8:449‑50.
drugs. The rapid reversal of narcotic depression may also
6. Zeppetella G. The WHO analgesic ladder: 25 years on. Br J Nurs
cause nausea, vomiting, diaphoresis, and circulatory stress. 2011;20:S4, S6.
The initial dose is 1–2 mg IV at 2‑ to 3‑minute intervals 7. Goodwin SA, Caro DA, Wolf SJ Jagoda AS, Charles R, Marett BE, et al.
until reaching the desired effect of reversal. It can be given Clinical policy: Procedural sedation and analgesia in the emergency
department. Ann Emerg Med 2005;45:177‑96.
undiluted as a bolus or as an IV infusion with 5% dextrose
8. Anesthesiologists Task Force on Sedation and Analgesia by
in water or 0.9% normal saline. As with flumazenil, a drip Non‑Anesthesiologists. Practice guidelines for sedation and analgesia
may need to be started due to the longer half‑life of the by non‑anesthesiologists. Anesthesiology 2002;96:1004‑17.
offending agent. Naloxone has a half‑life of 30–81 minutes. 9. Michael A, PevelingOberhag J, Herrmann E, Zeuzem S, Bojunga J,
Friedrich‑Rust M. Evaluation of the Integrated Pulmonary Index® during
Adverse effects include seizures, ventricular tachycardia,
nonanesthesiologist sedation for percutaneous endoscopic gastrostomy.
ventricular fibrillation, acute narcotic abstinence syndrome, J Clin Monit Comput 2021;35:1085–92.
and return of pain.[29] 10. Tobias JD, Leder M. Procedural sedation: A review of sedative agents,
monitoring and management of complications. Saudi J Anaesth
In summary, PSA is generally safe in older adults. What is not 2011;5:395‑410.
11. Sheta SA. Procedural sedation analgesia. Saudi J Anaesth 2010;4:11‑6.
acceptable is undertreating pain or inadequately sedating 12. Goudra B, Nuzat A, Singh PM, Borle A, Carlin A, Gouda G. Association
a stable patient. All the usual precautions should be taken. between type of sedation and the adverse events associated with
One should consider any comorbidities that could make the gastrointestinal endoscopy: An analysis of 5 years’ data from a tertiary
patient more at risk of adverse reactions or complications. center in the USA. Clin Endosc 2017;50:161–9.
13. Doyle WL, Perrin L. Emergence delirium in a child given oral midazolam
Older patients may be at higher risk for oxygen desaturation, for conscious sedation. Ann Emerg Med 1994;24:1173–5.
but they usually respond quickly to supplemental oxygen. 14. Noda N, Hara M, Ise S, Ose M, Tatsuta M, Nagaoka A, et al. Comfort and
Geriatric patients usually require lower doses of medications. safety of bronchoscopy performed under sedation and local anesthesia
They tend to be more sensitive to medications, with in elderly patients. Medicine (Baltimore) 2020;99:e22561.
15. Zaal IJ, Devlin JW, Hazelbag M, Klein Klouwenberg PM,
slower metabolism, less physiologic reserve to handle van der Kooi AW, Ong DS, et al. Benzodiazepine‑associated delirium
side effects, and a smaller volume of distribution. The use in critically ill adults. Intensive Care Med 2015;41:2130–7.
of drugs for sedation in elderly patients requires careful 16. Goudra BG, Singh PM. Remimazolam: The future of its sedative
consideration of their age‑related changes in physiology and potential. Saudi J Anaesth 2014;8:388‑91.
17. Hu B, Jiang K, Shi W, Xiao S, Zhang S, Zhang Y, et al. Effect of
pharmacokinetics. The choice of drug should be based on remimazolam tosilate on respiratory depression in elderly patients
the patient’s medical condition, comorbidities, and potential undergoing gastroscopy: A multicentered, prospective and randomized
adverse effects. Moreover, the administration should be done study. Drug Des Devel Ther 2022;16:4151‑9.
by trained personnel with close monitoring of vital signs 18. Lu K, Wei S, Ling W, Wei Y, Ran X, Huang H, et al. Remimazolam
versus propofol for deep sedation/anesthesia in upper gastrointestinal
and level of consciousness to prevent complications such as endoscopy in elderly patients: A multicenter, randomized controlled
respiratory depression. trial. J Clin Pharm Ther 2022;47:2230–6.
19. Kerker A, Hardt C, Schlief HE, Dumoulin FL. Combined sedation with
Acknowledgements midazolam/propofol for gastrointestinal endoscopy in elderly patients.
BMC Gastroenterol 2010;10:11.
The authors would like to thank Dr. Sarah B. Delvi MBBS, for
20. Belleville JP, Ward DS, Bloor BC, Maze M. Effects of intravenous
helping out during the preparation of this review. dexmedetomidine in humans: Sedation, ventilation and metabolic rate.
Anesthesiology 1992;77:1125–33.
Financial support and sponsorship 21. Chen M, Sun Y, Li X, Zhang C, Huang X, Xu Y, et al. Effectiveness of single
Nil. loading dose of dexmedetomidine combined with propofol for deep
sedation of endoscopic retrograde cholangiopancreatography (ERCP)
in elderly patients: A prospective randomized study. BMC Anesthesiol
Conflicts of interest 2022;22:85.
There are no conflicts of interest. 22. Mei B, Meng G, Xu G, Cheng X, Chen S, Zhang Y, et al. Intraoperative

538 Saudi Journal of Anesthesia / Volume 17 / Issue 4 / October-December 2023

 Eldawlatly, et al.: PSA in elderly patients

sedation with dexmedetomidine is superior to propofol for elderly and maintenance. Anaesthesia 1988;43(Suppl):109‑11.
patients undergoing hip arthroplasty: A prospective randomized 26. Willman E, Andolfatto G. A prospective evaluation of “ketofol” (ketamine/
controlled study. Clin J Pain 2018;34:811‑7. propofol combination) for procedural sedation and analgesia in the
23. Wickström I, Holmberg I, Stefánsson T. Survival of female geriatric emergency department. Ann Emerg Med 2007;49:23‑30.
patients after hip fracture surgery. A comparison of 5 anesthetic methods. 27. Kanonidou Z, Karystianou G. Anesthesia for the elderly. Hippokratia
Acta Anaesthesiol Scand 1982;26:607‑14. 2007;11:175‑7.
24. Stefánsson T, Wickström I, Haljamäe H. Hemodynamic and metabolic 28. Abdolrazaghnejad A, Banaie M, Tavakoli N, Safdari M, Rajabpour-
effects of ketamine anesthesia in the geriatric patient. Acta Anaesthesiol Sanati A. Pain management in the emergency department: A review
Scand 1982;26:371‑7. article on options and methods. Adv J Emer Med. 2018;2:e45.
25. Maneglia R, Cousin MT. A comparison between propofol and ketamine 29. van Dorp E, Yassen A, Dahan A. Naloxone treatment in opioid addiction:
for anaesthesia in the elderly. Haemodynamic effects during induction the risks and benefits. Expert Opin Drug Saf 2007;6:125-32.

Saudi Journal of Anesthesia / Volume 17 / Issue 4 / October-December 2023 539