Anesthesia for Geriatric

Anesthesia for the Anesthesia for the Geriatric PatientGeriatric Patient

Departement of Anesthesiology and ReanimationDepartement of Anesthesiology and ReanimationMedical Faculty Sumatera Utara University, Medical Faculty Sumatera Utara University,

H.Adam Malik General HospitalH.Adam Malik General HospitalMedan, IndonesiaMedan, Indonesia

20032003

Hasanul Arifin,Hasanul Arifin,

II. Concept of Aging and Geriatrics. Concept of Aging and Geriatricsa. No concensus as to when the geriatric a. No concensus as to when the geriatric

(elderly) years begin.(elderly) years begin. Nevertheless, elderly Nevertheless, elderly ≥ 65 years ≥ 65 years

older & “aged” older & “aged” ≥ 80 years ≥ 80 years b. Many changes due to age-related disease have been b. Many changes due to age-related disease have been erroneously attributed to aging.erroneously attributed to aging. cc. Mechanisms that control aging remain unknown. Mechanisms that control aging remain unknown

Hasanul-2003Hasanul-2003

OXIDATIVE OXIDATIVE STRESSSTRESS

DECREASED DECREASED ANTIOXIDANT & ANTIOXIDANT &

SCAVENGING SCAVENGING CAPACITYCAPACITY

DAMAGE TO DAMAGE TO MEMBRANES, MEMBRANES, PROTEINS, & PROTEINS, &

GENETIC GENETIC INTEGRITYINTEGRITY

INCREASED INCREASED INTRACELLULAR INTRACELLULAR FREE-RADICALSFREE-RADICALS

““CYLE OF CYLE OF AGING”AGING”

DECREASED DECREASED BIOENERGETIC BIOENERGETIC

CAPACITYCAPACITY

LOSS OF LOSS OF TISSUE AND TISSUE AND

ORGAN ORGAN FUNCTIONAL FUNCTIONAL

RESERVERESERVE

INCREASED INCREASED SUSCEPTIBILITY TO SUSCEPTIBILITY TO DISEASE, INFECTION DISEASE, INFECTION

AND INJURYAND INJURY

INCREASED INCREASED PROBABILITY PROBABILITY

OF DEATHOF DEATH

At a cellular level, At a cellular level, (within mitochondria)(within mitochondria)

Hand book of Clinical Anesthesia: Barash.PG, Cullen.BF, Stoelting.RK :2001, 649Hand book of Clinical Anesthesia: Barash.PG, Cullen.BF, Stoelting.RK :2001, 649Hasanul-2003Hasanul-2003

II.II. Aging and Organ FunctionAging and Organ Function1.1. Physiologically young Physiologically young elderly patients who elderly patients who

maintain greater than average functional maintain greater than average functional capacities (maximum organ system function that capacities (maximum organ system function that is greater than basal demands)is greater than basal demands)

2.2. Physiologically old Physiologically old when organ function when organ function declines at an earlier age than usual or at a declines at an earlier age than usual or at a morerapid rate.morerapid rate.

3.3. Changes in organ function with aging are highly Changes in organ function with aging are highly variable among individuals even in absence of variable among individuals even in absence of disease. This change is significantly altered by disease. This change is significantly altered by activity level, social habits, diet and genetic activity level, social habits, diet and genetic background.background.

A. Function of organ system changing and increasing ageA. Function of organ system changing and increasing age


Safety margin Safety margin organ system organ system functional reservefunctional reserve to to meet additional demands (increased CO, CO2 meet additional demands (increased CO, CO2 excretion, protein synthesis)excretion, protein synthesis)

B.B.

1.1. The functional reserve of all organ systems is The functional reserve of all organ systems is progressively and significantly decreased in progressively and significantly decreased in elderly patients.elderly patients.

2.2. Physiologic aging Physiologic aging increased susceptibility of increased susceptibility of elderly patients to stress and disease-induced elderly patients to stress and disease-induced organ system decompensation .organ system decompensation .


III. Cardiopulmonary functionIII. Cardiopulmonary functionA.A. Cardiac function,Cardiac function,

1.1. The demand for cardiopulmonary function is The demand for cardiopulmonary function is maintained in elderly patients by daily exercise.maintained in elderly patients by daily exercise.

2.2. Short-term increases in cardiac output are Short-term increases in cardiac output are accomplished in the elderly patient initially by accomplished in the elderly patient initially by modest increases in heart rate and then by modest increases in heart rate and then by progressively larger stroke volume.progressively larger stroke volume.

3.3. Aging decreases the inotropic and chronotropic Aging decreases the inotropic and chronotropic responses to neurally mediated adrenergic responses to neurally mediated adrenergic stimulation such that maximum heart rate and stimulation such that maximum heart rate and inotropic response are age limited.inotropic response are age limited.

4.4. Passive ventricular filling, which normally occurs Passive ventricular filling, which normally occurs during the early phase of diastole, is decreased in during the early phase of diastole, is decreased in elderly patients (stiffer and less compliant ventricle)elderly patients (stiffer and less compliant ventricle)


5.5. Age-related diastolic dysfunction Age-related diastolic dysfunction elderly elderly patients more dependent on synchronous atrial patients more dependent on synchronous atrial contraction for complete ventricular filling.contraction for complete ventricular filling.

a.a. VR VR stroke volume compromise stroke volume compromiseb.b. Perioperative arterial hypotension is Perioperative arterial hypotension is

predictable more common in elderly than in predictable more common in elderly than in young.young.

6.6. Systolic arterial hypertension Systolic arterial hypertension fibrotic fibrotic replacement of elastic tissue within the replacement of elastic tissue within the cardivascular system.cardivascular system.

B. B. Repiratory functionRepiratory functionFibrous connective tissue Fibrous connective tissue loss of lung elastic recoil loss of lung elastic recoil(inevitable emphysema-like changes)(inevitable emphysema-like changes)

1. FRC , VC , Residual Volume 1. FRC , VC , Residual Volume 2. Costochondral calcification 2. Costochondral calcification thorax more rigid thorax more rigid WoB WoB 3. Age related 3. Age related acute postoperative ventilatory failure acute postoperative ventilatory failure4. Age related 4. Age related decrease in arterial oxygenation decrease in arterial oxygenation


5. More vulnerable to developing transient apnea when given drug 5. More vulnerable to developing transient apnea when given drug (opioid, benzodiazepin) post operative.(opioid, benzodiazepin) post operative.

6. The treshold stimulus needed for vocal cord closure 6. The treshold stimulus needed for vocal cord closure risk of aspiration of gastric content.risk of aspiration of gastric content.

IV. Hepatorenal And Immune FunctionIV. Hepatorenal And Immune Function..A.A.1.1. Liver tissue mass decreases about 40% by the age of 80 years, and Liver tissue mass decreases about 40% by the age of 80 years, and

hepatic blood flow is proportionally decreased.hepatic blood flow is proportionally decreased.2.2. Hepatic metabolism may be age and gender specific.Hepatic metabolism may be age and gender specific.3.3. Hepatic enzyme activities are unchanged by aging and normal Hepatic enzyme activities are unchanged by aging and normal

value for plasma transaminases are unchanged.value for plasma transaminases are unchanged.

B.B.1.1. Renal tissue mass decrease by about 30%, and RBF decreases by Renal tissue mass decrease by about 30%, and RBF decreases by

about 50% by the eighth decade of life.about 50% by the eighth decade of life.2.2. Serum creatinine concentration usually remains within the Serum creatinine concentration usually remains within the

normal range.normal range.3.3. Intravascular and intracellular dehydrationIntravascular and intracellular dehydration

C.C.Elderly patients exhibit decreased immune responsivenessElderly patients exhibit decreased immune responsiveness


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8080707060605050404030302020101000

8080707060605050404030302020101000

kgkg kgkg

BODY BODY LIPIDLIPID

OTHER OTHER TISSUETISSUE

BODY BODY WATERWATER

MENMEN

WOMENWOMEN

YOUNGYOUNG YOUNGYOUNGOLDEROLDER OLDEROLDERAge related changes in body composition are gender specific. Increases in body fat offset bone loss and 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 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 component of lean tissue mass produces contraction of intracellular water and a decrease in total body weight.weight. Hand book of Clinical Anesthesia: Barash.PG, Cullen.BF, Stoelting.RK :2001, 654Hand book of Clinical Anesthesia: Barash.PG, Cullen.BF, Stoelting.RK :2001, 654

Aging in men results in a progressive and generalized loss of Aging in men results in a progressive and generalized loss of skeletal muscle mass and reciprocal increases in the lipid fractionskeletal muscle mass and reciprocal increases in the lipid fraction

V. METABOLISM, BODY COMPOSITION, AND PHARMACOKINETICSV. METABOLISM, BODY COMPOSITION, AND PHARMACOKINETICSA.A.


1.1. BMR , heat production ,BMR , heat production , special risk for intraoperative special risk for intraoperative hypothermiahypothermia• Intraoperative decreases in core body temperature Intraoperative decreases in core body temperature

average almost 1average almost 100C per hour.C per hour.• The time needed for postoperative spontaneous The time needed for postoperative spontaneous

rewarming may be prolonged.rewarming may be prolonged.2.2. Progressive impairment of the ability to handle an Progressive impairment of the ability to handle an

intravenous glucose challengeintravenous glucose challenge

B.B. Plasma volume, red cell mass, and ECF volumes are Plasma volume, red cell mass, and ECF volumes are normally well maintained in normotensive elderly normally well maintained in normotensive elderly individuals who maintain their habits of daily physical individuals who maintain their habits of daily physical activity.activity.

C.C. Increases in total body lipid content enlarge the volume Increases in total body lipid content enlarge the volume of distribution of drugs (inhaled anesthetics, of distribution of drugs (inhaled anesthetics, barbiturates, benzodiazepin). This may delay recovery in barbiturates, benzodiazepin). This may delay recovery in elderly patients .elderly patients .


VI. CENTRAL NERVOUS SYSTEMVI. CENTRAL NERVOUS SYSTEMA.A. Aging decreases brain size, and neurons that Aging decreases brain size, and neurons that

synthesize neurotransmitters (dopamine, synthesize neurotransmitters (dopamine, norepinephrine, tyrosine, serotonin) seem to be most norepinephrine, tyrosine, serotonin) seem to be most affected.affected.

B.B. CBF decreases in proportion to decreased brain CBF decreases in proportion to decreased brain tissue.tissue.1.1. Autoregulation is well maintained, and the Autoregulation is well maintained, and the

cerebral vasoconstrictor response to cerebral vasoconstrictor response to hyperventilation remains intact.hyperventilation remains intact.

2.2. In the absence of cerebrovascular disease, the In the absence of cerebrovascular disease, the conventional guidelines for controlled hypotension conventional guidelines for controlled hypotension during neurosurgical procedures are appropriate during neurosurgical procedures are appropriate for elderly.for elderly.

C.C. Comprehension and long term memory are well Comprehension and long term memory are well maintained.maintained.

D.D. Hypothalamic-pituitary-adrenal dysregulation and Hypothalamic-pituitary-adrenal dysregulation and increased plasma cortisol levels.increased plasma cortisol levels. Hasanul-2003Hasanul-2003

VII. PERIPHERAL NERVOUS VII. PERIPHERAL NERVOUS SYSTEMSYSTEMA.A. The tresholdThe treshold intensities of stimuli needed to intensities of stimuli needed to

initiate all forms of perception are increased.initiate all forms of perception are increased.B.B. Aging is associated with a gradual but Aging is associated with a gradual but

significant deterioration of electrical conduction significant deterioration of electrical conduction along efferent motor pathway. along efferent motor pathway.

C.C. Cholinoreceptors at the skeletal muscle .Cholinoreceptors at the skeletal muscle .


B.B. Baroreceptors that maintain cardiovascular Baroreceptors that maintain cardiovascular homeostasis are progressively impaired. homeostasis are progressively impaired.

C.C. ANS ANS “underdamped” “underdamped” delayed restabilization delayed restabilization during hemodynamic stress. General anesthesia, during hemodynamic stress. General anesthesia, spinal, epidural anesthesia (pharmacologic spinal, epidural anesthesia (pharmacologic sympathectomy) sympathectomy) systemic hypotension that is systemic hypotension that is more severe compared with young adult.more severe compared with young adult.

VII. AUTONOMIC NERVOUS SYSTEMVII. AUTONOMIC NERVOUS SYSTEMA.A. Neurons in the sympathoadrenal pathways decline Neurons in the sympathoadrenal pathways decline

by at least 15% by 80 years of age. Nevertheless, by at least 15% by 80 years of age. Nevertheless, plasma nor-epinephrine are significantly .plasma nor-epinephrine are significantly .• Aging markedly and progressively depresses Aging markedly and progressively depresses

autonomic end organ responsivenessautonomic end organ responsiveness• Aging produces an endogenous ß blockade.Aging produces an endogenous ß blockade.• Aging appears to produce little change in Aging appears to produce little change in αα--

adrenergic or muscarinic cholinoceptor activity.adrenergic or muscarinic cholinoceptor activity.


IX. ANALGESIC AND ANESTHETIC REQUIREMENTIX. ANALGESIC AND ANESTHETIC REQUIREMENT

A.A. There are decreased segmental dose requirement There are decreased segmental dose requirement for local anesthetics during epidural, and slightly for local anesthetics during epidural, and slightly higher levels of sensory blockade undergoing higher levels of sensory blockade undergoing spinal anesthesia.spinal anesthesia.

B.B. MAC decrease predictably with increasing age.MAC decrease predictably with increasing age.C.C. Systemic morphine requirements are inversely Systemic morphine requirements are inversely

related to patient age.related to patient age.D.D. Barbiturates, and benzodiazepines are less Barbiturates, and benzodiazepines are less

consistent than those for inhaled anesthetics.consistent than those for inhaled anesthetics.E.E. Doses of muscle relaxants and steady state Doses of muscle relaxants and steady state

plasma concentrations required to produce a plasma concentrations required to produce a given degree of neuromuscular blockade are not given degree of neuromuscular blockade are not changed by aging. The clinical duration of action changed by aging. The clinical duration of action is prolonged if the elimination of the muscle is prolonged if the elimination of the muscle relaxant is dependent on hepatic or renal relaxant is dependent on hepatic or renal clearance mechanisms.clearance mechanisms. Hasanul-2003Hasanul-2003

I I I I I I I I I I I I I I

0 20 40 60 80 100 1200 20 40 60 80 100 120

DOXACURIUMDOXACURIUM

PIPECURONIUMPIPECURONIUM

METOCURINEMETOCURINE

CURARECURARE

PANCURONIUMPANCURONIUM

CISATRACURIUMCISATRACURIUM

VECURONIUMVECURONIUM

ATRACURIUMATRACURIUM

ROCURONIUMROCURONIUM

MIVACURIUMMIVACURIUM

RI-OLDER ADULTRI-OLDER ADULTRI-YOUNGER ADULTRI-YOUNGER ADULT

RECOVERY INDEXRECOVERY INDEX(T(T2525-T-T7575, minutes), minutes)

RI : Recovery Index , the time required for spontaneous recovery RI : Recovery Index , the time required for spontaneous recovery from 25% to 75% of the control evoked neuromuscular response.from 25% to 75% of the control evoked neuromuscular response.

Hand book of Clinical Anesthesia: Barash.PG, Cullen.BF, Stoelting.RK :2001, 658Hand book of Clinical Anesthesia: Barash.PG, Cullen.BF, Stoelting.RK :2001, 658Hasanul-2003Hasanul-2003

X. PERIOPERATIVE MANAGEMENT X. PERIOPERATIVE MANAGEMENT ANDANDOUTCOME.OUTCOME.

A.A. Age-related disease and not aging is primarily responsible Age-related disease and not aging is primarily responsible for the progressive increase in morbidity and mortality of for the progressive increase in morbidity and mortality of elderly surgical patients (see table)elderly surgical patients (see table)

Age-Related DiseasesAge-Related Diseases• HypertensionHypertension• Ischemic Heart DiseaseIschemic Heart Disease• CHFCHF• Peripheral vascular diseasePeripheral vascular disease• COPDCOPD• Renal diseaseRenal disease• Diabetes MellitusDiabetes Mellitus• ArthritisArthritis• DementiaDementia

Hand book of Clinical Anesthesia: Barash.PG, Hand book of Clinical Anesthesia: Barash.PG, Cullen.BF, Stoelting.RK :2001, 659Cullen.BF, Stoelting.RK :2001, 659 Hasanul-2003Hasanul-2003

The high prevalence of polypharmacy associated with The high prevalence of polypharmacy associated with chronic disease and its treatment also produce an age –chronic disease and its treatment also produce an age –related increase in adverse drug reaction.related increase in adverse drug reaction.

Drugs Likely to Be Taken by Drugs Likely to Be Taken by Elderly PatientsElderly Patients

• antihypertensivesantihypertensives• antidepressantsantidepressants• anticoagulantsanticoagulants

• oral hypoglycemicsoral hypoglycemics• corticosteroidscorticosteroids• beta-blockersbeta-blockers

• sedativessedatives

Hand book of Clinical Anesthesia: Barash.PG, Cullen.BF, Stoelting.RK :2001, 659Hand book of Clinical Anesthesia: Barash.PG, Cullen.BF, Stoelting.RK :2001, 659


Adverse surgical outcome show a Adverse surgical outcome show a predominance of dysfunction of cardiac, predominance of dysfunction of cardiac, pulmonary and renal mechanisms, pulmonary and renal mechanisms, emphasizing the importance of preoperative emphasizing the importance of preoperative evaluation and preparation as it relates to evaluation and preparation as it relates to these organ systems.these organ systems.

BB..

The choice of anesthetic drug or technique does The choice of anesthetic drug or technique does not seem to influence the overall outcome in not seem to influence the overall outcome in elderly patients .elderly patients .

CC..

Newer intravenous drugs (remifentanil, Newer intravenous drugs (remifentanil, cisatracurium) minimize dependence on organ cisatracurium) minimize dependence on organ system functional reserve, whereas newer system functional reserve, whereas newer inhaled anesthetics (sevoflurane, desflurane) inhaled anesthetics (sevoflurane, desflurane) provide rapid recovery of consciousness even provide rapid recovery of consciousness even in elderly patientsin elderly patients

1.1.


Prompt and complete postoperative recovery of Prompt and complete postoperative recovery of mental function is particularly important in elderly.mental function is particularly important in elderly.

2.2.

Less likelyLess likely to experience nausea and to experience nausea and vomiting, but more likely to experience vomiting, but more likely to experience mental confusion following outpatient surgery mental confusion following outpatient surgery compared with young adults.compared with young adults.The most common cause of failure to The most common cause of failure to emerge promptly from anesthesia is too emerge promptly from anesthesia is too much anesthesia or too many anesthetic much anesthesia or too many anesthetic drugs.drugs.Nerve palsies due to regional anesthesia Nerve palsies due to regional anesthesia seem to occur more often compared with seem to occur more often compared with younger adults.younger adults.


Anesthetic management is appropriate, surgical Anesthetic management is appropriate, surgical convalescence uncomplicated, convalescence uncomplicated, full return of full return of cognitive function to preoperative levels may cognitive function to preoperative levels may require 5-10 days.require 5-10 days.

D.D.

Physical management in OT & RR, require Physical management in OT & RR, require special precautions, special precautions, gentle and careful gentle and careful positioningpositioning

EE..

•Postoperative bleeding & bacterial infection Postoperative bleeding & bacterial infection more likely compared with young adultsmore likely compared with young adults•Diastolic dysfunction, ventricular stiffness, Diastolic dysfunction, ventricular stiffness, rate of iv.fluid (too fast) may precipitate rate of iv.fluid (too fast) may precipitate pulmonary edemapulmonary edema•Untreated pain & related emotional stress Untreated pain & related emotional stress immune responsiveness immune responsiveness

F.F.



Mr. George BushedMr. George Bushed

Anesthesia for Geriatric

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