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Dr.

GERTRUDE SIYAKA
Consultant Anaesthesiologist
Steve Biko Academic
Hospital

Introduction
Normal physiological changes
associated with ageing
Pharmacokinetics and
pharmacodynamics in the elderly
Pre-operative assessment
Day case surgery
Anaesthesia for orthopaedic surgery
Post operative complications
References

Life expectancy in US and Europe now


74-80yrs
Medical progress most effective in
change
Demographical data indicate the elderly
most rapidly growing of population
Use of health care services by elderly
disproportionately higher than younger
patients
Elderly patients now routinely undergo
operative procedures

Ageing a complex multifactorial process


Universal and progressive physiological
process marked by declining end organ
function, imbalance haemostatic
mechanisms, increasing pathologic processes
Theories on numerous and diverse:
evolutionary, molecular, cellular and
systemic
Include mutation accumulation, programmed
cell death, cumulative environmental
damage, free radical damage
End result is impaired function and
progressive decline

Age related changes occur in all organs

1. Cardiovascular system
Main contributor for adverse outcome
in peri-operative period
Heart
LV hypertrophy frequently evolves and
related to elevated SVR
Cardiac mass increases- concentric
hypertrophy
Interstitial fibrosis in myocardium leads
to poor contractility

Stiffness myocardium affects diastolic


relaxation as well as systolic contraction
Prolonged systolic myocardial contraction
then ensues
LV relaxation time delayed at time mitral
valve opening
Early diastolic filling declines
Age related increase in LA volume and
contribution to diastolic filling shows
importance of atrial kick.
Ventricular eccentric hypertrophy and loss
wall tension may lead to valve closure
deficiency and regurgitant valves

Aortic valve sclerosis common


CO decreases linearly after 3rd
decade at 1% per year even in
healthy individuals
80 yr old will have approx 50% CO
compared to when was age 20
CI decreases at 80% per year

Vasculature
Arteriosclerosis is the hallmark feature
Contributing factors are: hypertension
,hypercholesterolemia, oxidative stress
and genetic disposition
Arteriosclerosis an irreversible process
CEA and AAA repair most frequently
performed procedures in elderly

Adrenergic sensitivity
Plasma CATS levels after stimuli not
been shown to diminish
Blunted B-receptor responsiveness
possibly due to down regulation and
decreased agonist binding to receptor
Increase in vigil tone
There is 20% loss of HR response
during exercise in 75 yr old compared
to 25 yr old

2. Respiratory system
Typical barrel chest appearance results in
increased work of breathing and reduced
compliance
Loss of elastic recoil within the lung and changes
in surfactant production leads to limited maximal
expiratory flow
Lung volumes: increase in RV, closing capacity,
FRC , TLC (minimal). Decrease in VC
Flow :progressive decrease in FEV1 /FVC
Oxygenation: decrease efficiency in alveolar gas
exchange resulting in PaO2and increase alveolar
arterial gradient
Impaired response to hypoxia, hypercarbia and
mechanical stress

3.Renal
Renal mass decreases by 30% by age
80
Renal blood flow and creatinine
clearance decrease
Poor electrolyte handling and capacity
to concentrate or dilute urine
Excretion of some anaesthetic agents
is impaired

4. Nervous system
Brain weight declines by 10%
Cerebral atrophy common
Cerebral blood supply reduced and
vertebrobasilar insufficiency common
Gradual decline in cognitive function,
memory and reasoning performance
Confusion common
Altered sleep pattern
Thermoregulation: poor response to
hypothermia

Pharmkinetics influenced by in plasma


protein binding, lean body mass,
changes in circulating blood volume and
metabolism and excretion of drugs
Lean body mass reduced
Protein binding sites reduced
Decrease in circulating blood volumehigher than expected initial plasma
concentration of drugs
Polypharmacy
Elderly more sensitive to anaesthetic
agents

Get medical history, current functional


status and medication
ASA status
Lab investigation as appropriate for
anticipated surgery and medical issues:
CXR,12 lead ECG, FBC , U/E and CT scan
as appropriate
Worry about polypharmacy
Enquire about social circumstances
Continue B blockers, but discontinue
ACEIs, Digoxin
Premedicate if appropriate

NO MAGIC BULLETS
Effects of initial dose on single
patient highly variable
Smaller doses compared to younger
patients
Low threshold for invasive monitoring
Position carefully to avoid pressure
and nerve injuries
Avoid hypothermia

An excellent option for carefully selected


pts
Pre-operative evaluation to determine
functional reserve , physical status ,and
rational pre-operative testing but must be
done early enough to allow for
interventions
Suitable for minimally invasive surgery
(eyes, urology) in maximally co-morbid pts
Any anaesthetic technique :LA ,RA ,GA
Premed as appropriate.

ADVANTAGES

RA provides good post


op analgesia
Peri-op MI less frequent
Oculocardiac reflex less
frequent
PONV unlikely
Short stay in PACU
Pts eat ,drink earlier
Discharge home earlier

DISADVANTAGES

Control IOP limited


Long surgery
contraindicated
Need pt co-operation
Pt coughing ,movement
not avoided
Ventilation not
controlled( hypercarbia,
hypoxia)

GA may be needed
Same drugs used but consideration
to dosing the elderly
LMA can safely be used but proviso
Manage pain adequately
Consider prophylaxis for PONV

Number of elderly pts in orthopaedic


surgery steadily growing (hip fractures,
OA, rheumatoid arthritis)
Elderly pts may have significant organ
dysfunction; cardiorespiratory, renal
and neurological.
They may be malnourished
No single clear anaesthetic technique.
RA preferred
Use of cement during surgery known to
be associated with intra-operative
morbidities

Tourniquet use common


Sedation often needed when RA used
DVT prophylaxis necessary for major
joint surgery
Antibiotics routinely used but must be
given before tourniquet
Blood loss may significant in revision
surgery
Neuraxial blockade with opioid provides
good analgesia

Prolonged use of urinary catheters


should be avoided
Goal is early and efficient rehab
Central neuraxial blockade reduces
surgical stress by blocking nociceptive
inputs
Geriatric pts have decreased functional
organ system reserve and are thus
tolerate surgical stress poorly
RA recommended the elderly and has
advantage over GA

Older pt at risk for complications in perioperative period due to co-morbid diseases


and the ageing process
Cardiovascular complications include MI,
dysrhythmias esp. AF, and cardiac arrest
Pulmonary complications: atelactasis ,
pneumonia
Neurological complications: stroke, POD,POCD.
Post operative delirium(POD): acute
confusional state
Post operative cognitive dysfunction(POCD):
long term impairment in memory,
concentration ,language and social integration

Surgery is now performed in older


,sicker elderly patients
Ageing is associated with numerous
physiological changes
Surgery not always benign because
of high prevalence of co-morbidities
Adjust anaesthetic technique
Aim to minimise peri-operative
complications

Available on request