Anesthetic Management

of The Elderly Patients

Presented by:
Tia Sabrina, S,Ked
Citra Seftiani, S.Ked
Thavamalar Silvarajoo, S.Ked
Indah Kencana, S.Ked

Supervisor:
Dr. Endang Melati Maas , Sp.An

Introduction
Background

Aging process is a process that converts healthy

adults into frail accompanied by a decrease in
reserves almost all physiological systems and
accompanied by increased susceptibility to
disease and death.
Approach and management of the operation and
anesthesia on geriatric patients are different and
often more complex than in younger patients.

 Purpose

To identify the management of anesthesia

in geriatric patients, so it can reduce
mortality and morbidity risk in geriatric
patients during surgery.

Age-Related Anatomic &

Physiological Changes

Cardiovascular System
Reduced

arterial compliance results in

increased afterload, elevated systolic
blood pressure, and left ventricular
hypertrophy.
The left ventricular wall thickens at the
expense of the left ventricular cavity.
Some myocardial fibrosis and calcification
of the valves are common.

 Baroreceptor

function is depressed
Cardiac output typically declines with age
Increased vagal tone and decreased
sensitivity of adrenergic receptors lead to
a decline in heart rate; maximal heart rate
declines by approximately one beat per
minute per year of age over 50
Fibrosis of the conduction system and loss
of sinoatrial node cells increase the
incidence of dysrhythmias, particularly
atrial fibrillation and flutter

 Diminished

cardiac reserve in many

elderly patients may be manifested as
exaggerated drops in blood pressure
during induction of general anesthesia

Like

infants, elderly patients have less

ability to respond to hypovolemia,
hypotension, or hypoxia with an increase
in heart rate

Respiratory System
Elasticity

is decreased in lung tissue,

allowing overdistention of alveoli and
collapse of small airways

The

former reduces the alveolar surface

area, which decreases the efficiency of
gas exchange

Airway

collapse increases residual volume

and closing capacity

 Some

airways close during part of normal

tidal breathing, resulting in a mismatch of
ventilation and perfusion.

Decrease

arterial oxygen tension by an

average rate of 0.35 mm Hg per year.

Both

anatomic and physiological dead

space increase.

Prevention of perioperative hypoxia includes:

a longer preoxygenation period prior to
induction
a higher inspired oxygen concentrations
during anesthesia
small increments of positive end-expiratory
pressure

Metabolic & Endocrine Function

Basal

and maximal oxygen consumption

declines with age.
Heat production decreases, heat loss
increases, and hypothalamic temperatureregulating centers may reset at a lower
level.
Increasing insulin resistance leads to a
progressive decrease in the ability to
handle glucose loads.

 The

neuroendocrine response to stress

appears to be preserved or slightly
decreased in most healthy elderly patients.

Aging

is associated with a decreasing

response to -adrenergic agents
("endogenous -blockade")

Circulating

norepinephrine levels are

reported to be elevated in elderly patients.

Renal Function
Renal

blood flow and kidney mass (eg,

glomerular number and tubular length)
decrease with age
Renal function as determined by
glomerular filtration rate and creatinine
clearance is reduced
Impairment of sodium handling,
concentrating ability, and diluting capacity
predisposes elderly patients to
dehydration or fluid overload.

 The

response to antidiuretic hormone and

aldosterone is reduced.

The

ability to reabsorb glucose is

decreased.

The

combination of reduced renal blood

flow and decreased nephron mass
increases the risk of elderly patients for
acute renal failure in the postoperative
period.

 As

renal function declines, so does the

kidney's ability to excrete drugs

The

decreased capacity to handle water

and electrolyte loads makes proper fluid
management more critical, elderly patients
are more predisposed to developing
hypokalemia and hyperkalemia.

Gastrointestinal Function
Liver

mass declines as a person ages,

with a corresponding decrease in hepatic
blood flow. Hepatic function (reserves)
declines
The rate of biotransformation and albumin
production decreases.
Plasma cholinesterase levels are reduced
in elderly men.
Gastric pH tends to rise, whereas gastric
emptying is prolonged

Nervous System
Brain

mass decreases with age; neuronal

loss is prominent in the cerebral cortex,
particularly the frontal lobes.
Cerebral blood flow also decreases about
1020% in proportion to neuronal losses.
The synthesis of some neurotransmitters,
such as dopamine, and the number of
their receptors are reduced.

 Serotonergic,

adrenergic, and
-aminobutyric acid (GABA) binding sites
are also reduced.

Astrocytes

and microglial cells increase in

number.
Degeneration

of peripheral nerve cells

results in prolonged conduction velocity
and skeletal muscle atrophy.

 Aging

is associated with an increasing

threshold for nearly all sensory modalities,
including touch, temperature sensation,
proprioception, hearing, and vision.

Dosage

requirements for local (Cm:

minimum anesthetic concentration) and
general (MAC: minimum alveolar
concentration) anesthetics are reduced.

A longer

duration of action should be

expected from a spinal anesthetic.

 Elderly

patients often take more time to

recover completely from the central
nervous system effects of general
anesthesia, particularly if they were
confused or disoriented preoperatively.

The

incidence of postoperative delirium

appears similar with both regional and
general anesthesia

Musculoskeletal
Muscle

mass is reduced.
Neuromuscular junctions thicken.
Skin atrophies with age and is prone to
trauma from adhesive tape, electrocautery
pads, and electrocardiographic electrodes.
Veins are often frail and easily ruptured by
intravenous infusions.
Degenerative cervical spine disease can
limit neck extension potentially making
intubation difficult.

Anesthetic Management of The

Elderly Patients

Preoperative Assessment of
the Elderly
The preoperative evaluation has served
two primary functions:
to

alert the perioperativecare providers to

physiologic conditions that may alter
perioperative management
to determine if medical intervention is
indicated before proceeding.

to

provide an index of risk, therefore

contributing to decisions about the most
appropriate intervention,
and to provide baseline data on which
the success of a surgical intervention
might be judged.

Pre-operative Assesment
1. Assesment:
A full history of patient
Clinical assessment - cardiac, respiratory
and renal disease
ECG
Chest X-ray

2. Resuscitation/optimisation preoperatively
3. Consider day case surgery
4. Decision to operate.

Monitoring
Some

aspects that consider perioperative

care in elderly patients:
- Rehydration, if there is dehydration
- Gastrointestinal disorders resolved
- Overcoming sepsis
- Overcoming hemorrhage (blood loss), if any
- Overcoming edema in congestive heart
failure

Age-Related Pharmacological
Changes

 The

reduced volume of distribution for watersoluble drugs can lead to higher plasma
concentrations; conversely, an increased
volume of distribution for lipid-soluble drugs
can lower their plasma concentration.

Because

renal and hepatic functions decline

with age, reductions in clearance prolong the
duration of action for many drugs.

 Distribution

and elimination are also

affected by altered plasma protein binding
Albumin, which tends to bind acidic drugs
(eg, barbiturates, benzodiazepines, opioid
agonists), typically decreases with age.

The

principal pharmacodynamic change

associated with aging is a reduced
anesthetic requirement, represented by a
lower MAC.

Inhalational Anesthetics
The

MAC for inhalational agents is reduced by

4% per decade of age over 40 years.

Onset

of action will be more rapid if cardiac

output is depressed, whereas it will be delayed if
there is a significant ventilation/perfusion
abnormality

The

myocardial depressant effects of volatile

anesthetics are exaggerated in elderly patients,
whereas the tachycardiac tendencies of
isoflurane and desflurane are attenuated

Thus, in contrast to its effects on younger patients,

isoflurane reduces cardiac output and heart rate in
elderly patients.

Recovery from anesthesia with a volatile anesthetic

may be prolonged because of an increased volume
of distribution (increased body fat), decreased
hepatic function (decreased halothane metabolism),
and decreased pulmonary gas exchange.

The rapid elimination of desflurane may make it the

inhalation anesthetic of choice for elderly patients.

Nonvolatile Anesthetic Agents

In

general, elderly patients display a lower

dose requirement for propofol, etomidate,
barbiturates, opioids, and benzodiazepines.

Although

propofol may be close to an ideal

induction agent for elderly patients because
of its rapid elimination, it is more likely to
cause apnea and hypotension than in
younger patients.

 Concomitant

administration of midazolam,
opioids, or ketamine further decreases
propofol requirements

In

the case of thiopental, enhanced

sensitivity appears to be primarily due to
pharmacokinetics factors.

The

initial volume of distribution for

etomidate significantly decreases with
aging

 Pharmacokinetics

for these opioids are not

significantly affected by age. Dose
requirements for the same EEG end point
using fentanyl and alfentanil are 50%
lower in elderly patients.

Aging

increases the volume of distribution

for all benzodiazepines, which effectively
prolongs their elimination half-lives.

Muscle Relaxants
The

response to succinylcholine and

nondepolarizing agents is unaltered with aging.
Decreased cardiac output and slow muscle
blood flow, however, may cause up to a 2-fold
prolongation in onset of neuromuscular blockade
in elderly patients.
Recovery from nondepolarizing muscle relaxants
that depend on renal excretion (eg, metocurine,
pancuronium, doxacurium, tubocurarine) may be
delayed due to decreased drug clearance.

 Decreased

hepatic excretion from a loss

of liver mass prolongs the elimination halflife and duration of action of rocuronium
and vecuronium.

The

pharmacological profiles of
atracurium and pipecuronium are not
significantly affected by age.

Elderly

menbut not elderly women

may display a slightly prolonged effect
from succinylcholine due to lower plasma
cholinesterase levels.

Fluid Management
Careful

peri-operative fluid balance is mandatory in the

elderly.
Patients are more often underfilled than overloaded,
although care should be taken to avoid fluid overload:
excess fluids in an elderly patient, especially in the
presence of renal failure, can cause pulmonary oedema.
Conversely, dehydration, which can be difficult to
assess in the elderly, can precipitate renal failure.
Regular review of fluid therapy is essential after major
surgery.

Conclusion
Physiological

changes occur in the elderly patients

Management of anesthesia in geriatric patients
differ from younger patients
Drug selection and dose determination of
anesthesia must also be adjusted with the
conditions of geriatric patients.
Fluid therapy should be considered more carefully
considering cardiac function and renal function.

References

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Thank You