GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD...

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GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults. AGS

Transcript of GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD...

Page 1: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

GERIATRIC ANESTHESIA:AN INTRODUCTION

Jeannette Lee, MDAnesthesiology Resident

Ruben J. Azocar, MD Associate Professor of

Anesthesiology

THE AMERICAN GERIATRICS SOCIETY

Geriatrics Health Professionals.

Leading change. Improving care for older adults.

AGS

Page 2: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

OBJECTIVES

• Review the ongoing demographic changes in the elderly segment of the population

• Analyze the impact of the growing geriatric populations in health care

• Summarize the most important physiologic changes that occur with aging

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Page 3: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

ELDERLY POPULATION

• “Elderly” is defined as >65 years old

• “Very old” is defined as >85 years old

• The elderly population currently comprises 12% of the US population

Projected to increase to 20% by 2040

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Page 4: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

ELDERLY POPULATION IN THE US

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Page 5: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

ELDERLY POPULATION IN THE US

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Page 6: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

THE ELDERLY AS A PROPORTIONOF THE US POPULATION

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Page 7: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

GLOBAL ELDERLY POPULATION

• In 2000 the global population >65 years old was estimated to be 420 million

• It is projected that by 2010, the elderly population will increase 847,000 per month

Slide 7http://www.census.gov/prod/2001pubs/p95-01-1.pdf

Page 8: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

GLOBAL ELDERLY POPULATION

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Page 9: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

PROCEDURES FOR THE ELDERLY

• From 19942005 the average number of inpatient procedures per year in patients >65 years old increased from 6,500,000 to 7,353,000

• Currently 35% of all surgical procedures are performed in elderly patients

• More than half of the elderly population will have at least one procedure done before they die

Slide 9www.cdc.gov/nchs/data/hus/hus07.pdf#102

Page 10: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

POSTOPERATIVE MORTALITYIN THE ELDERLY

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• Monk et al reported a prospective observational study of 1064 patients undergoing noncardiac surgery

• > 65 yo had a 1-year mortality rate of 10.3% vs. 5.5% in all patients

• >65 yo had a relative risk of 1-year postoperative mortality of 4.459, which was the third highest risk factor, after having 3 or more comorbidities or an ASA of 3 or 4.

Monk TG et al. Anesth Analg. 2005;100:4-10.

Page 11: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

PHYSIOLOGIC CHANGES WITH AGING

• Functional and structural changes occur in most organ systems

• Although the basal function may remain stable in various organs systems, the functional reserve and the ability to compensate under physiologic stress are greatly reduced

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Page 12: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

PHYSIOLOGIC CHANGES WITH AGING: BODY COMPOSITION

• Skeletal muscle mass decreased

• Percentage of body fat increased

• Total body water decreasedWater-soluble drugs: reduced volume of distributionLipid-soluble drugs: increased volume of distribution

• DO2 and heat production decreased

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Page 13: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

PHYSIOLOGIC CHANGES WITH AGING:CENTRAL NERVOUS SYSTEM

• Brain mass decreases, mainly from loss of neural tissue

• 10%20% reduction in cerebral blood flow

• Decreased number of serotonin, acetylcholine, and dopamine receptors

• Decline in memory, reasoning, perception

• Disturbed sleep/wake cycle

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Page 14: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

PHYSIOLOGIC CHANGES WITH AGING:CARDIOVASCULAR SYSTEM

• LV hypertrophy and decreased compliance

• Increase in vascular rigidity Decreased compliance of venous vessels

• Desensitization of β-adrenergic receptors Decreased PNS tone and increased SNS tone

• SVR and SBP increased

• SV and CO decreased

• Diastolic LV dysfunction

• Decreased maximally attainable HR

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Page 15: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

PHYSIOLOGIC CHANGES WITH AGING:PULMONARY SYSTEM

• ↑ Central airway size and ↓ small airway diameter no change in airway resistance

• ↓ Functional alveolar surface area

• ↓ Gas exchange ↓ PaO2 and ↑ Aa gradient

• ↑ Lung compliance and RV leads to ↑ FRC• No changes in TLC

Result is ↑ RV/TLC and FRC/TLC ratios

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Page 16: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

PHYSIOLOGIC CHANGES WITH AGING:PULMONARY SYSTEM

Decrease Increase• Respiratory muscle strength • Chest wall height• Respiratory center sensitivity• Chest wall compliance• Effective cough and swallow ↑

aspiration risk

• DLCO2

• PIMAX and PEMAX

• ERV and VC• FVC, FEV1, FEV1/VC, and FEF

at low lung volumes

• Chest wall stiffness• AP diameter• Closing volume and closing

capacity

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Page 17: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

PHYSIOLOGIC CHANGES WITH AGING:RENAL SYSTEM

• Tissue mass decreased

• Perfusion decreased

• GFR decreased

• Reduced ability to dilute and concentrate urine and conserve sodium

• Drug clearance decreased

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Page 18: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

PHYSIOLOGIC CHANGES WITH AGING:HEPATIC SYSTEM

• Tissue mass decreased

• Blood flow decreased

• Possible decrease in affinity for substrate

• Possible decrease in intrinsic activity

• Decreased first-pass metabolism of some drugs

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Page 19: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

PHYSIOLOGIC CHANGES WITH AGING: ENDOCRINE CHANGES

• ↓ ADH response to hypovolemia and hypotension

• ↓ Renin and aldosterone leads to ↓ response to sodium restriction and postural changes are blunted

• No changes in adrenocorticotropic hormone, cortisol, catecholamine production in adrenal medulla, or TSH

• Insulin release is impaired Impaired peripheral tissue resistance and decreased

clearance leads to ↑ plasma insulin levels and ↑ fat deposits

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Page 20: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

PHYSIOLOGIC CHANGES WITH AGING:PK AND PD ISSUES

• Protein binding ↓ Level of proteins Multiple medications interfere with drug binding sites ↑ Level of free unbound drug in plasma prolonged effect

• ↓ Lean and ↑ fat body mass ↑ Storage of lipid-soluble drugs prolonged effect and longer

time for elimination

• ↓ Circulating blood volume ↑ Initial plasma drug concentration

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Page 21: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

CONCLUSIONS

• The proportion of older individuals in the US population continues to rise

• Many of them will require surgery and anesthesia

• Physiologic changes of age have a great impact in the perioperative period

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Page 22: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

ACKNOWLEDGMENTS

• Supported by a grant from the Geriatric Education for Specialty Residents Program (GS), which is administered by the American Geriatrics Society and funded by the John A. Hartford Foundation of New York City

• Our gratitude to Dr. Alec Rooke for his assistance with many of these slides

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Page 23: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN.

Visit us at:

Facebook.com/AmericanGeriatricsSociety

Twitter.com/AmerGeriatrics

www.americangeriatrics.org

THANK YOU FOR YOUR TIME!

linkedin.com/company/american-geriatrics-society

Slide 23


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