Anesthesia in GERIATRIC patients

November 5, 2007
Waldemar P !iahaan, "#
Almost one third o$ all s%r&i'al patients are (5 )ears o$ a&e or older, and an even lar&er
$ra'tion is anti'ipated in the ne*t t+o de'ades There$ore %nless intentionall) limited to
pediatri's or obstetri' patients, ever) anesthesiolo&ist in 'ontemporar) pra'ti'e m%st
a',%ire e*pertise in &eriatri' medi'ine
This a$ternoon +e +ill dis'%ss the se'tions de$ine the '%rrent 'on'epts o$ a&in& that are
relevant to anestheti' pra'ti'e And present strate&ies %se$%l $or perioperative assessment
o$ the elderl) patient, and s%mmari-e pra'ti'al aspe'ts o$ anestheti' mana&ement and the
perioperative 'are o$ &eriatri' s%r&i'al patients
E*treme variabilit) o$ si&ns, s)mptoms, and ph)si'al presentation amon& older patients is
an essential 'hara'teristi' o$ &eriatri' medi'ine C%rrentl), ho+ever, there is no 'onsens%s
as to +hen the .&eriatri' era be&ins in h%man s%b/e'ts or +heter an) sin&le ph)siolo&i'
mar0er 'an identi$) an elderl)1patient
2or 'larit) and 'onsisten'), ho+ever, the terms .elderl)1and .&eriatri'1are %sed
s)non)mo%sl) in this dis'%ssion to des'ribe h%man s%b/e'ts +ho are (5 )ears o$ a&e or
older The term .a&ed1+ill be %sed to des'ribe individ%als older than 30 )ears
"ost st%dies o$ h%man a&in& are 'ross se'tional st%dies that meas%re ph)siolo&i'
parameters sim%ltaneo%sl) in )o%n& and elderl) s%b/e'ts
.)o%n&1and .old1patient &ro%ps bein& 'ompared o$ten di$$er not onl) in a&e, b%t also in
their overall ethni', anatomi', and bio'hemi'al 'hara'teristi's $ro &eneti' ba'0&ro%nd, o$
$or prior e*pos%re to in$e'tio%s a&ents
The me'hanisms that 'ontrol the a&in& pro'ess remain %n0no+n The impressive
'onsisten') o$ observed li$e span does not ne'essaril) impl) that there is a biolo&i'al
'lo'0 $or ea'h spe'ies
Instead, a&e related de'line in or&an and tiss%e $%n'tion ma) simpl) be the inevitable
a''%m%lation o$ nonspe'i$i' de&enerative phenomena
#e'linin& mitro'hondrial bioener&eti's ma) be the %nderl)in& me'hanism $or a&e related
deterioration o$ 'ell%lar and or&an $%n'tion
Contemporar) de$initions o$ a&in& remain 'on'ept%al rather than ,%antitative A&in&
mani$ests itsel$ in mammalian spe'ies as de&enerative 'han&es in both the str%'t%re and
the $%n'tional 'apa'it) o$ or&ans and tiss%es
4o+ever, a more 'ontemporar) anal)sis des'ribes nonlinear 'han&e in ma*imal or&an
$%n'tion that $irst be'omes apparent $ollo+in& the )ears that represent the pea0 o$
somati' mat%ration, in the $o%rth de'ade o$ h%man li$e 5C6IC78 Additional de'rements
o$ $%n'tion d%rin& the middle ad%lt )ears appear to be relativel) s%btle, b%t s%bse,%entl)
be'ome pro&ressivel) more dramati' d%rin& the traditional )ears o$ &eriatri' senes'en'e,
5C6IC78 the seventh de'ade o$ li$e and be)ond Elderl) patients +ho maintain &reater
than avera&e $%n'tional 'apa'ities are 'onsidered .ph)siolo&i'all) )o%n&1 5C6IC78
When or&an $%n'tion de'lines at an earlier a&e than %s%al, or at a more rapid rate, elderl)
patients appear to be .ph)siolo&i'all) old1 5C6IC78 pa%se9
In all health) &eriatri' patients, ho+ever, ma*im%m or&an s)stem $%n'tion is &reater than
basal demand The di$$eren'e bet+een ma*imal or&an s)stem 'apa'it) and basal $%n'tion
represents or&an s)stem $%n'tional reserve :r&an s)stem $%n'tional reserve is the .sa$et)
mar&in1available to meet
2or an) or&an s)stem, .$%n'tional reserve1represents the di$$eren'e bet+een basal
5minimal8 and ma*imal or&an s)stem $%n'tion The a&e;related de'line in $%n'tional
reserve ma) not be 'lini'all) apparent %ntil demands made on the or&an s)stem are
in'reased b) stress, disease, pol)pharma'), or s%r&i'al intervention
As +e tal0 the 'ardiop%lmonar) $%n'tion, the a&in& heart in'reases o%tp%t to meet
imposed metaboli' demands as needed +ithin the limits o$ its ma*imal 'apa'it)
<n'er'onditions o$ s%bma*imal demand, m)o'ardial 'ontra'tilit) appears to remain
%n'ompromised b) in'reasin& a&e at least %ntil the ei&hth de'ade The heart, %nli0e other
ma/or or&ans, does not atroph) +ith a&e
!hort term demands $or in'reased 'ardia' o%tp%t are met at $irst b) modest in'reases in
heart rate, and then b) in'reasin& le$t ventri'%lar end diastoli' vol%mes and press%res,
'han&es that prod%'e pro&ressivel) lar&er stro0e vol%mes
=e'a%se a&in& red%'es the inotropi' and 'hronotropi' responses to adrener&i' stim%lation
and beta a&onists, ma*imal heart rate is a&e limited, and %nli0e )o%n& ad%lts, older ad%lts
e*hibit little enhan'ement o$ e/e'tion $ra'tion %nder these 'ondition
The a&in& le$t ventri'le is thi'0er and less elasti' than its )o%n&er 'o%nterpart, e*hibitin&
s)mmetri' h)pertroph) and an in'rease in 'olla&en 'ross lin0in& in the m)o'ardial
')tos0eleton to +hi'h the m)o')tes are atta'hed
The sti$$er ventri'le and atri%m do not %nder&o 'omplete rela*ation %ntil relativel) late in
diastole, and passive ventri'%lar $illin& 5+hi'h o''%rs d%rin& the earl) phase o$ diastole8
is si&ni$i'antl) red%'ed
As this $i&%re sho+ %s, s%b/e'ts +ho are elderl) have a sli&htl) hi&her end diastoli'
ventri'%lar vol%me and lar&er end diastoli' stro0e vol%me as +ell as sli&htl) elevated
intra'avitar) press%re thro%&ho%t the 'ardia' ')'le d%e to in'reased m)o'ardial sti$$ness
and dela)ed a'tive rela*ation d%rin& diastole
!)stoli' h)pertension +ith in'reased arterial p%lse press%re is 'ommon in the &eriatri'
pop%lation It is a ma/or 'ardiovas'%lar ris0 $a'tor 'a%sed b) a &rad%al in'rease in lar&e
arter) sti$$ness d%e to $ibroti' repla'ement o$ elasti' tiss%es d%rin& the ad%lt )ears
A&e related loss o$ tiss%e elasti'it) o''%rs in the l%n& and the 'ardiovas'%lar s)stem
There is an in'rease in $ibro%s 'onne'tive tiss%e +ithin the l%n& paren'h)ma, as +ell as
de&eneration and 'ross lin0in& o$ l%n& elastin There$ore, all elderl) individ%als
event%all) demonstrate some de&ree o$ emph)sema li0e in'reases in l%n& 'omplian'e
4o+ever, 'al'i$i'ation and sti$$enin& o$ the 'osto'hondral /oints o$ the thora* red%'e
'hest +all 'omplian'e,
so net p%lmonar) 'omplian'e is essentiall) %n'han&ed
Nevertheless, loss o$ l%n& elasti' re'oil is the primar) anatomi' me'hanism b) +hi'h
a&in& e*erts deleterio%s e$$e'ts on p%lmonar) &as e*'han&e
=rea0do+n o$ alveolar septae also red%'es total alveolar s%r$a'e area, in'reasin& both
anatomi' and alveolar dead spa'e
As +e see in this $i&%re, Total l%n& 'apa'it), 5the s%m o$ >ital Capa'it) ? shado+ed one
and resid%al vol%me8 $alls slo+l) in older ad%lts o$ either &ender >ital Capa'it) ho+ever
5the e*'han&eable &as vol%me8 is mar0edl) 'ompromised b) in'reases in thora'i' ri&idit)
and loss o$ ventilator) m%s'le po+er Resid%al vol%me in'reases be'a%se intrinsi' l%n&
elasti' re'oil is pro&ressivel) red%'ed
!o d%rin& &eneral anesthesia, P%lmonar) $%n'tion in older ad%lts is best des'ribed as
pro&ressive ventilation per$%sion mismat'h d%e to the deterioration o$ alveolar
ar'hite't%re and to anestheti' ind%'ed depression o$ a'tive h)po*i' p%lmonar)
vaso'onstri'tion
:pioid ind%'ed ri&idit) o$ the 'hest +all o''%rs more $re,%entl) in older ad%lts than in
)o%n&er ad%lts
The threshold stim%l%s ma&nit%de needed $or vo'al 'ord 'los%re is mar0edl) elevated,
in'reasin& the ris0 o$ p%lmonar) in/%r) d%e to aspiration o$ &astri' 'ontents in older
patients, espe'iall) i$ level o$ 'ons'io%sness is depressed
Conse,%entl), &eriatri' s%r&i'al patients are 'learl) at in'reased ris0 o$ %nre'o&ni-ed
respirator) $ail%re in the t)pi'al postoperative settin& o$ resid%al anestheti' depression
and the %se o$ opioids $or pain mana&ement
4epati' en-)me a'tivites are 'omparable to those o$ )o%n& ad%lts, b%t liver tiss%e mass
de'lines abo%t @0A b) the a&e o$ 30 )ears, and hepati' blood $lo+ is proportionall)
red%'ed 6oss o$ per$%sed hepati' tiss%e mass lar&el) e*plains the red%'ed rates o$
plasma 'learan'e and prolon&ed 'lini'al e$$e'ts o$ nar'oti's and man) other *enobioti's
in &eriatri' s%b/e'ts
In &eneral, a&e related di$$eren'es in the bindin& o$ dr%&s to plasma proteins do not a$$e't
pharma'o0ineti's si&ni$i'antl) in a 'lini'al 'onte*t
4o+ever, hepati' metabolism and dr%& biotrans$ormation ma) be altered %npredi'tabl)
in this patient s%bpop%lation be'a%se o$ s%stained e*pos%re to the intense pol)pharma')
o$ a&e related 'hroni' disease In addition, the hepati' s)ntheti' reserve needed $or
+o%nd healin& or response to sepsis ma) be inade,%ate
Almost one third o$ renal tiss%e mass is lost b) the ei&hth de'ade, and renal blood $lo+
de'reases b) abo%t B0A perde'ade be&innin& in earl) ad%lthood
"ore than BCD
rd
o$ the &lomer%li and t%b%lar str%'t%res disappear in the elderl), and in
some o$ the remainin& &lomer%li, s'lerosis impairs e$$e'tive $iltration b) prod%'in&
t%b%lar diverti'%li and d)s$%n'tional 'ontin%it) bet+een a$$erent and e$$erent &lomer%lar
arterioles
!er%m 'reatinine 'on'entration remains normal be'a%se loss o$ s0eletal m%s'le mass
imposes a pro&ressivel) smaller 'reatinine load
Geriatri' s%r&i'al patients do not appear to re,%ire a %ni,%e $l%id repla'ement proto'ol,
b%t their renal $%n'tional reserve is rarel) ade,%ate to +ithstand &ross disr%ptions o$
+ater and ele'trol)te balan'e #iminished thirst, poor diet, and the %se o$ di%reti' a&ents
to de'rease a&e related h)pertension also predispose debilitated elderl) s%r&i'al patients
+ith 'hroni' disease to intravas'%lar and intra'ell%lar deh)dration
Parti'%lar) in men, a&in& prod%'es a pro&ressive and &enerali-ed loss o$ s0eletal m%s'le
mass and atroph) o$ other metaboli'all) a'tive tiss%es in brain, liver, and 0idne) This
'han&e in bod) 'omposition b) red%'e basal metaboli' re,%irements b) B0 to B5A
'ompared +ith )o%n& ad%lts
In $a't, intraoperative 'ore temperat%re de'reases at a rate t+i'e as &reat as that observed
in )o%n& ad%lts %nder 'omparable 'onditions
=e'a%se m%s'le and liver provide stora&e $or 'arboh)drates, a&in& is also asso'iated +ith
impairement o$ the abilit) to handle a &l%'ose 'hallen&e
!o, $l%id repla'ement +ith &l%'ose 'ontainin& sol%tions in patients +ho are elderl)
sho%ld be limited to environments that permit $re,%ent meas%rement o$ blood s%&ar
levels
This $i&%re sho+ %s the a&e related 'han&es in bod) 'omposition I$ +e see these are a
&ender spe'i$i' In +omen, total bod) mass remains 'onstant be'a%se in'reases in bod)
$at, o$$set bone loss and intra'ell%lar deh)dration
In men, bod) mass de'lines despite maintenan'e o$ bod) lipid and s0eletal tiss%e
elements be'a%se a''eleratin& loss o$ s0eletal m%s'le and other 'omponents o$ lean
tiss%e mass prod%'es mar0ed 'ontra'tion o$ intra'ell%lar +ater
A&in& red%'es brain si-e Avera&e ad%lt brain mass is abo%t 20A less b) the a&e o$ 30
)ears The $ra'tion o$ intra'ranial vol%me o''%pied b) brain tiss%e $alls $rom E2 to 32A
over the same time period, +ith the most rapid red%'tion in &ra) matter tiss%e mass and
the &reatest rate o$ 'ompensator) in'rease in 'erebrospinal $l%id o''%rrin& a$ter the si*th
de'ade A&in&, in e$$e't, prod%'es a $orm o$ lo+;press%re h)dro'ephal%s
In &eneral, the most metaboli'all) a'tive, hi&hl) spe'iali-ed ne%ronal s%bpop%lations,
parti'%larl) those that s)nthesi-e ne%rotransmitters, appear to s%$$er the most severe
de&ree o$ attrition
These a&e related 'han&es +ithin the brain and spinal 'ord are +ell des'ribed
anatomi'all) b%t their $%n'tional si&ni$i'an'e remains %n'lear
The me'hanisms that 'o%ple re&ional 'orti'al and s%b'orti'al per$%sion to lo'al variation
o$ metaboli' demands are maintained and the blood brain barrier is $%n'tionall) inta't
A&in& does not impair a%tore&%lation o$ 'erebrovas'%lar resistan'e to 'han&es in arterial
blood press%re, and the 'erebral vaso'onstri'tor response to h)perventilation remains
inta't in the health) &eriatri' patient
!t%dies s%&&est that 'r)stalli-ed intelli&en'e s%'h as lan&%a&e s0ills and personalit) do
not de'line +ith in'reasin& a&e General 0no+led&e, 'omprehension, and lon& term
memor) are +ell maintained even in individ%als +ho are a&ed i$ the) remain ph)si'all)
$it and mentall) a'tive
It remains %n'lear +hether $l%id intelli&en'e and other 'o&nitive $%n'tions that re,%ire
immediate pro'essin& or rapid retrieval s%$$er intrinsi' deterioration or +hether the) are
'ompromised b) a&e related limitation o$ attention span
The threshold intensities o$ stim%li needed to initiate all $orms o$ per'eption, in'l%din&
vision, hearin&, to%'h, /oint position, sense, smell peripheral pain and temperat%re
in'rease d%rin& senes'en'e ThereFs a de&enerative 'han&es +ithin spe'iali-ed sense
or&ans s%'h as the pain &eneratin& "eissnerFs 'orp%s'les in s0in
In addition, attrition o$ the individ%al nerve $ibers +ithin a$$erent 'ond%'tion path+as in
both the peripheral nevo%s s)stem and spinal 'ord red%'e the velo'it) and amplit%de o$
evo0ed sensor) potentials Peripheral motor nerve 'ond%'tion velo'it) de'reases steadil)
thro%&ho%t ad%lthood and impairment o$ e$$erent 'orti'ospinal transmission in'reases the
laten') bet+een intention and onset o$ motor a'tivit)
"itho'ondrial vol%me +ithin s0eletal m%s'le 'ells is red%'ed, and ne%ro&eni' s0eletal
m%s'le atroph) '%ases the d)nami' stren&th and steadiness o$ s0eletal m%s'le in the
e*tremities to de'line 20 to 50A b) the a&e o$ 30 )ears
As in other parts o$ the peripheral nervo%s s)stem, ne%rons in s)mpathoadrenal path+a)s
are s%b/e't to si&ni$i'ant 'ell%lar attrition In addition, adrenal tiss%es atroph) and 'ortisol
se'retion de'lines at least B5A b) the a&e o$ 30 Nevertheless, plasma 'on'entrations o$
norepinephrine are 2;@$old hi&her in s%b/e'ts +ho are elderl) than in )o%n&er ad%lts
d%rin& sleep at rest and even in response to e*er'ise ind%'ed ph)si'al stress
The response to beta a&onists s%'h as isoproterenol are mar0edl) red%'ed In e$$e't,
a&in& prod%'es .endo&eno%s beta blo'0ade
Nevertheless, the inte&rated a%tonomi' re$le* responses that maintain 'ardiovas'%lar and
metaboli' homeostasis are pro&ressivel) impaired in individ%als +ho are elderl) This
ma) e*plain the in'reased in'iden'e and severit) o$ arterial h)potension seen in older
patients $ollo+in& anestheti' ind%'tion
=arore$le* responsiveness, the vaso'onstri'tor response to 'old stress, and beat to beat
heart rate responses $ollo+in& post%ral 'han&e in s%b/e'ts +ho are elderl) be'ome
pro&ressivel) less rapid in onset, smaller in ma&nit%de, and less e$$e'tive in stabili-in&
blood press%re %nder a variet) o$ 'ir'%mstan'es
The net e$$e't o$ the a&e related str%'t%ral and $%n'tional 'han&es +ithin the nervo%s
)stem des'ribed previo%sl) on pain related ne%rolo&i' $%n'tion remains 'ontroversial
The st%d) o$ ampli$i'ation, mod%lation, and sele'tivit) o$ a$$erent inp%t +ithin the spinal
'ord, thalam%s, and other lo'ation +ithin the a&in& nervo%s s)stem does not )et permit
broad &enerali-ations re&ardin& a&in& and per'eption o$ pain
Per'eived intensit) o$ pain perioperativel) is e*tremel) %npredi'table and appears to
depend $ar more on an*iet), personalit), and the prospe't o$ lon& term debilit) than on
a&e itsel$
Nevertheless, parenteral morphine re,%irements are 'learl) inversel) related to patient
a&e and essentiall) independent o$ bod) +ei&ht
!imilarl), +hen a $i*ed dose and vol%me o$ lo'al anestheti' is %sed, hi&her levels o$
sensor) blo'0ade o''%r in patients %nder&oin& spinal anesthesia
!e&mental dose re,%irements $or epid%ral anal&esia are similarl) red%'ed, and more
'ephalad levels o$ ne%ral blo'0ade 'arr) a &reater ris0 o$ h)potension in the elderl)
The e$$e't o$ nervo%s s)stem a&in& on re,%irements $or &eneral anesthesia is less
'ontroversial =et+een )o%n& ad%lthood and the &eriatri' era, relative minim%m alveolar
'on'entration 5"AC8 val%es $or the ne+er inhalational a&ents de'line b) as m%'h as
D0A The same de'rement seen +ith older anestheti's
The me'hanisms prod%'in& a&e related in'reases in sensitivit) to anestheti' a&ents
remain %n0no+n, b%t the 'onsisten') o$ this phenomenon $or anestheti' a&ents +ith
mar0edl) di$$erent 'hemi'al 'hara'teristi's s%&&ests that it re$le'ts a $%ndamental
ne%roph)siolo&i' pro'ess
This $i&%re /%st to sho+ )o% the a&e related de'line in relative anestheti' re,%irement
5"inim%m alveolar 'on'entration8 in %nsedated h%man s%b/e'ts is a 'onsistent
'hara'teristi' reported $or a +ide variet) o$ inhaled and in/e'ted anestheti' a&ent
The data $or the e$$e't o$ a&in& on the pharma'od)nami's or dose re,%irements $or
opioids barbit%rates and ben-odia-epines are less 'onsistent thant that $or inhalational
nestheti's
There is 'onsiderable 'ontrovers) as to +hether the 'lini'all) apparent a&e related
in'rease in the poten') o$ these dr%&s is tr%l) a pharma'od)nami' 5dr%& sensitivit)8
phenomenon or +heter it simpl) re$le'ts a&e related 'han&es in redistrib%tion
pharma'o0ineti's 5mole'%lar dr%& disposition8
#%ration o$ ne%rom%s'%lar blo'0ade is also mar0edl) prolon&ed $or rela*ants +ith
hepati' or renal elimination be'a%se plasma 'learan'e de'lines +ith in'reasin& a&e
4o+ever, anta&onism o$ the e$$e'ts o$ blo'0in& dr%&s and re'over) o$ ne%rom%s'%lar
transmission sho%ld be %n'han&ed
There probabl) are no health) patients +ho are .too old1 $or anesthesia, even amb%lator)
s%r&i'al pro'ed%res A&e related disease, and not a&in& itsel$, lar&el) determines the
morbidit) and mortalit) that 'hara'teri-es an elderl) s%r&i'al pop%lation
2ollo+in& orthopaedi' s%r&er), the speed and e*tent to +hi'h a patient +ho is elderl)
re'overs $%ll $%n'tion has also been sho+n to depend on $%n'tional level prior to s%r&er)
"orbidit) and mortalit) rates there$ore are hi&her in elderl) s%r&i'al patients lar&el)
be'a%se this s%r&i'al patient s%bpop%lation has a &reater in'iden'e and severit) o$
'on'%rrent disease, and &reater e*pos%re to invasive medi'al interventions, than do
)o%n&er ad%lts
Pol)pharma') also prod%'es an a&e related in'rease in adverse dr%& rea'tions that
'ompli'ate perioperative mana&ement
As this $i&%re sho+ %s there is in'reased rates o$ perioperative morbidit) and mortalit) in
s%r&i'al patients +ho are elderl) 'an be attrib%ted primaril) to intera'tions bet+een a&e
related de'reases in or&an s)stem reserve, a hi&h prevalen'e o$ disease in the elderl) and
the inherent ris0 asso'iated +ith therap) and s%r&i'al intervention
Conse,%entl), ade,%ate time $or dia&nosis, treatment, and preparation o$ the anestheti'
plan is essential i$ the rate and severit) o$ 'ompli'ations are to be red%'ed
Elderl) patients at lo+ ris0 ma) be able to pro'eed +itho%t $%rther testin& or
preparataion, and intermediate ris0 patients are no+ believed to bene$it s%bstantiall) $rom
perioperative beta blo'0ade
2or the elderl) s%r&i'al patient at hi&h 'ardia' ris0, 'oronar) an&io&raph) prior to
ele'tive ma/or s%r&er) ma) be indi'ated
Ne+er inhalational a&ents s%'h as sevo$l%rane and des$l%rane appear to be the a&ents o$
'hoi'e to preserve le$t ventri'%lar $%n'tion a$ter 'ardiop%lmonar) b)pass in hi&h ris0,
elderl) 'oronar) s%r&er) patients
Nevertheless altho%&h man) 'lini'al st%dies have sho+n that some perioperative
'ompliations are asso'iated more $re,%entl) +ith on $orm o$ anesthesia than another, it
ma) not be possible to determine +hether there is a sin&le .best1 anestheti' $or patients
+ho are elderl)
In older s%r&i'al patients, deeper maintenan'e anestheti' levels are asso'iated +ith hi&her
B )ear post operative death rates "ale &ender ma) be additional 'o$a'tors that in'rease
lon& term mortalit) in &eriatri' s%r&i'al patient pop%lation
The %se o$ ne+er intraveno%s a&ents s%'h as remi$entanil and 'isatra'%ri%m minimi-e
dependen'e on or&an s)stem $%n'tional reserve $or dr%& elimination
Ne+er inhalation a&ents s%'h as sevo$l%rane and espe'iall) des$l%rane also provide more
rapid re'over) o$ 'ons'io%sness in the ad%lt +ho is a&ed than +as possible +ith
iso$l%rane
ThereFs less na%sea and vomitin& in older ad%lts a$ter &eneral anesthesia b%t a &reater
li0elihood o$ prolon&ed postoperative 'on$%sion
2%ll re'over) o$ ps)'homotor $%n'tion is some+hat dela)ed in older patients, even a$ter
t)pi'all) brie$ o%tpatient anesthesia +ith propo$ol
In addition, nerve palsies, resid%al paresthesias, and other ne%rapra*ias asso'iated +ith
re&ional anesthesia o''%r more o$ten than in )o%n& ad%lts
Even +hen anestheti' mana&ement o$ the older patient is appropriate and s%r&i'al
'onvales'en'e %n'ompli'ated, $%ll ret%rn o$ 'o&nitive $%n'tion to preoperative levels
a$ter a prolon&ed &eneral anestheti' ma) re,%ire %p to 2 +ee0s
The ph)si'al mana&ement o$ patients +ho are elderl) in the operatin& room and
a$ter+ard also re,%ires spe'i$i' pre'a%tions A&ed s0in and bones are $ra&ile, /oints are
sti$$, and their ran&e o$ motion is limited, espe'iall) i$ 'ompromised b) a&e related
arthriti' pro'esses
Avoidin& h)pothermia is important, ho+ever, a'tive heatin& devi'es in 'onta't +ith
poorl) per$%sed s0in or 'onne'tive tiss%e press%re points 'an ,%i'0l) prod%'e is'hemi'
lesions re,%irin& s%r&i'al treatment
In all patients +ho are elderl), postoperative bleedin& diatheses or h)per'oa&%lable states
and ba'terial in$e'tion are more $re,%ent than in )o%n&er ad%lts
<ntreated pain and related emotional stress itsel$ ma) also si&ni$i'antl) impair imm%ne
responsiveness in older ad%lts and in'rease the ris0 o$ perioperative in$e'tion There$ore,
an anestheti' plan that in'l%des postoperative epid%ral s)mpathe'tom) and anal&esia, or a
parenteral s)mpatheti' mod%lator ma) be o$ spe'ial val%e in the elderl) s%r&i'al patient
:verall, ho+ever, paitents +ho are elderl) and a&ed do not re,%ire a spe'ial 0ind o$
anestheti' A +ell 'ond%'ted anestheti' o$ an) t)pe is a sa$e and appropriate anestheti'
plan i$ attention to dosa&e and 'are$%l assessment o$ anestheti' dept are %sed Good
perioperative 'are o$ the &eriatri' patient simpl) re,%ires the hi&hest standards o$
dia&nosis and 'ontrol o$ pree*istin& disease, as +ell as 'lini'al vi&ilan'e and meti'%lo%s
deliver) o$ anestheti' and postoperative 'are
T4AN7 G:<9