Geriatric

anaesthesia
Contents :
• Introduction
• Physiological and pathological changes in old age
• Anaesthesia implications
• Pre operative assessment
• Intraop management
• Post op complications
• WHO CLASSIFICATION:
• 60 - 75 = Elderly
• 76 - 90 = old
• > 90 = very old
• Aging is a progressive physiological process characterized by :

• Decreased end organ reserve

• Decreased functional capacity
• Imbalance of homeostatic mechanisms
• Increased incidence of pathological process
Elderly patients have higher rates of hospital morbidity and mortality
compared to younger patients

As a person ages, their anatomy and physiology undergo many

changes that become more apparent with increasing age

Loss of functional reserves impairs an individual's ability to cope with

physiological challenges such as anaesthesia and surgery

This increased risk is related to the normal physiological processes of

ageing and increased prevalence of coexisting systemic disease
Physiological and pathological
changes in aging :
Cardiovascular system
• Normal aging manifests as changes in vascular, sympathetic
tone ,myocardium ,cardiac conduction system ,valves and
baroreceptor system
• Decreased cardiac output
• Cardiac valves :thickening and calcification of valves
• Aortic stenosis is more common with age
• Anaesthesia implications : avoiding tachycardia and hypotension
during anaesthesia is important to avoid MI
• Sympathetic and autonomic system :
• Decreased response to physiological derangements
• Decreased sensitivity of beta adrenergic receptors
• Baroreceptor impairment
• Anaesthesia implications : lower maximal heart rate ,limited
response to beta agonists
• Increased incidence of orthostatic hypotension and
intraoperative heamodynamic instability
• Increased risk of VTE
• AF is most common in older population
• Vascular and myocardial change:
Respiratory system
• Upper respiratory tract changes :
• Edentulous
• Loss of buccal fat ( difficult bag and mask )
• Decreased cervical spine extension and joint
stiffness( difficult intubation)
• Weak pharyngeal muscles ,decreased mucocilary clearance ,
less effective cough
• Decreased esophageal motility ,less effective upper airway
protective reflexes ( increased incidence of aspirations and
post op pneumonia )
• Decreased hypopharangeal and genioglossus muscle tone
leading to airway obstruction and increased incidence of OSA
Increased Decreased
•Chest wall stiffness •Respiratory muscle
•Residual volume strength
•Closing volume •Respiratory centre
•V/Q mismatch sensitivity to hypoxia and
hypercarbia
•Elastic recoil of the lung
•Vital capacity
•FEV 1
•PaO2
• Preventive strategies of aspirations and pneumonia :
1. Using regional or neuraxial anaesthesia instead of general
anaesthesia which interfere with cough reflex and
mucocilliary clearance
2. Avoid long acting NMB and ensure adequate reversal
3. Opiod sparing analgesia strategies
4. Neutralizing stomach acid with non particulate antacids
• Closing capacity increases with age
• FRC reduced relative to closing
capacity
• Pulmonary reserve decreased
• partial pressure of arterial oxygen
decreases with age
• Anaesthesia implications :
• Due to above changes older adults
are predisposed to atelectasis of
lung
• To minimize atelectasis in post op
period early mobilization , chest
physio and incentive spirometry
have to be included
Renal system:
• Cortical atrophy due to glomerular sclerosis
• Renal blood flow and GFR decreases with age
• Decreased response to RAAS , vasopressin results in
electrolyte and acid base derangements and not able to
tolerate hyper or hypovolemia
• Increased incidence of uti and urinary retention post op
leading to agitation or delirium
GIT AND HEPATIC SYSTEMS:
• Size and mass of liver decreases with age due to hepatocytes
death and decrease in blood flow ,so reserve function decrease
but synthetic function still intact
• Metabolism : phase 1 - slow
• Phase 2 - not effected
• Increased incidence of malignancies , NAFLD , Insulin resistance
Musculoskeletal system :

• Lean muscle mass decrease by 1% per year

• Muscle strength decrease by 3%/ year
• Muscle function and quality decrease faster than muscle
quantity
• Decreased total body fat and subcutaneous fat along with
age related dysregulation of cutaneous circulation leads to
temperature dysregulation and also effect wound healing
• Most of patients have joint stiffness , osteoarthritis and limit
joint mobility ,proper care must be taken in these patients
during positioning
Central nervous system :
• Due to aging older patients can present with cognitive
decline , memory loss ,sleep derangements ,dementia ,
movement disorder , depression these in turn can increase
the risk of delirium
• Increased sentivity to anaesthetic medications
• Decreased volume of csf
• Decreased epidural space
• Increased permeability of dura making them sensitive for
neuraxial anaesthesia
• Blunted response to hypoxia and hypercarbia so BZD should
be used with caution as premedication
• Decreased neurotransmitters such as acetylcholine and
dopamine, loss of neuronal cells and demyelination causes
slower nerve conduction speeds and increased latency.
Overall, this leads to a general decline in performance and
increased risk of cognitive dysfunction.
• increased visual , hearing disturbances contributing to
cognitive impairment
pre operative assessment :

• age related comorbs associated with adverse outcomes in elderly so it is

important to assess and optimize them pre operative
• CGA determines and optimise person medical , psychosocial and functional
capabilities and limitations
• components of CGA:
• systemic evaluation
• functional status
• frailty
• sensory impairment
• substance abuse
• nutrition
physical assessment and
comorbidities :
• detailed history of comorbid conditions , its impact on daily
life and medications
• posture , skin integrity , dentition , gait , mobility
• mobility :
• mobility assessment overlaps with funtional assesssment
• if there are any risk factors related to mobility patient can be
benefited by muscle strengthening or balance retraining to
decrease the falls
Nutrition assessment:( malnutrition universal screening tool):
● BMI - ( < 18.5 kg/ m2)
● S.albumin-(< 3gm/dl)
● Unintentional weight loss > 10% in 6 months

More predisposed to:

● Mostly infectious complications (eg; surgical site infection,
pneumonia, UTI)
● Wound complications ( eg; dehiscence, anastomosis leak)
● Increasing length of stay.

● history of total calories intake , history for specific vitamin and

mineral deficiencies have to be noted
● these patients can be benifited by preop nutritional supplementation
Functional and frailty screening:

• It is a decreased reserve to physiological stress and is

characterized by decline across organ systems
• Or accumulation of comorbid conditions that can result in
overall physiological vulnerability
• Frailty is associated with increased morbidity
• It is a risk factor for delirium
• Prehabilitation and palliative care can be advised for the
patient for optimization
Functional assesment:
Cognitive assessment:

• Occult preoperative cognitive impairment is common with incidence of

20% of patients over 65 years of age
• Baseline cognitive assessment is also helpful in delirium risk stratification
• post operative delirium is a independent risk factor postop morbidity and
mortality upto one year
• Some brief cognitive screening tools are as follows :
post op delirium:

• an acute decline in cognitive function and attention, with evidence from

the history that this is due to physiologic derangement, a medication, or
multi-factorial.
• 3 motor subtypes of delirium :
• hypoactive
• hyperactive
• mixed
• tools for diagnosis : CAM , CAM-ICU (for mechanically ventilated pt )
Risk factors for post op delirium
Treatment of delirium:
Risk factors for post op pulmonary
complications
Intraoperative concerns:

• Goals :
• Limit surgical stress
• Maintain functional reserve
• Aims :
• Safe and smooth anaesthesia with good cardiovascular
control and quick emergence with minimal post op cognitive
dysfunction
• Stable vital parameters and patient regain protective
physiological function as rapidly as possible
hypothermia :

• periop hypothermia is temp less than 36 degrees

• causes : impaired thermoregulation
• decrease muscle mass
• decreased metaboilic rate
• vascular reactivity
• cold temp in ot
• decrease in subcutaneous fat
• inbitory thermoregulatory funtion by anaesthesia
drugs
• Hypothermia is associated with adverse events
• surgical site infections
• cardiac events
• coagulopathy leading to surgical bleeding
• increased oxygen consumption due to shivering.
• prevention:
• 1. Core temperature should be monitored in surgeries lasting
more than 30 minutes.
• 2. Patient warming with forced air warmers and/or warmed
IV fluids should be used in older patientswho are undergoing
procedures longer than 30 minutes to avoid hypothermia.
 Regional vs general anesthesia :
• Regional anesthesia preferred if patient is cooperative
• Advantage :
• Lower incidence of PDPH
• Decreased stress response to surgical stimulus and blood loss
• Decreased incidence of thromboembolism
• Good post op analgesia ,early ambulation and discharge
• Less risk of aspiration
• Ensure good recognition of ischemic attack and better
assessment of mental status
Disadvantages:
• Difficulty in controlling the level of block
• Increased sensitivity of local anaesthesia
• Limited power of adaptation to vasomotor changes
• Difficult in technique due to calcified ligaments and
ankylosis of joints
• Increased incidence of nerve palsies and neuralgia .
General anaesthesia:

• Adequate preoxygenation should be done

• Short acting BZD should be used and dose titration
should be done
• During induction drugs should be slowly titrated ,so
that there is no drastic fall in blood pressure
• Long acting NMD can be avoided
• Anticipation of difficult bag and mask and difficult
airway is required
Pharmacology and aging :
there is reduced receptor number , increased receptor sensitivity ,
postreceptor transduction hence there is increased sensitivity to
anaesthesia drugs
• decreased TBW so less dose of drug is required
• lean body mass and albumin decrease in central
compartment so raised peak concentration and slow
redistribution leading to prolonged action
• renal clearance of drugs decreases with age
• liver blood flow decreases ( drugs with high extraction ratio
elimination decreases )
POSTOP PAIN:

• pain assessment :
• cognitively intact elderly patient : numerical or
verbal descriptors
• cognitive impaired : pain in advanced dementia
modalities for pain management :
• opioid free anaesthesia
• multimodal analgesia
• use of regional blockade
• patient controlled analgesia
Thank you