6.anesthesia for the geriatric patient

7/27/2019 6.Anesthesia for the Geriatric Patient

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ANESTHESIA FOR THE GERIATRICPATIENT

I. concept of aging and geriatricsA. No concensus as to when the geriatric (elderly) years begin.

Nevertheless : elderly 65 years, older & aged 80 yearsB. Many changes due to age-related disease have been erroneously

attributed to aging.C. Mechanisms that control aging remain unknown

II. Aging and Organ FunctionA. FUNCTION OF ORGAN SYSTEM CHANGING AND INCREASING AGE

1. Physiologically young elderly patients who maintain greater than averagefunctional capacities (maximum organ system function that is greater thanbasal demands)

2. Physiologically old when organ function declines at an earlier age thanusual or at a morerapid rate

3. Changes in organ function with aging are highly variable among individualseven in absence of disease. This change is significantly altered by activitylevel, social habits, diet and genetic background.

B. SAFETY MARGIN ORGAN SYSTEM FUNCTIONAL RESERVE TO MEET ADDITIONAL DEMAND(INCREASED CO, CO2 EXCRETION, PROTEIN SYNTHESIS)1. The functional reserve of all organ systems is progressively and

significantly decreased in elderly patients.2. Physiologic aging increased susceptibility of elderly patients to stress

and disease-induced organ system decompensation .

III.Cardiopulmonary FunctionA. CARDIAC FUNCTION1. The demand for cardiopulmonary function is maintained in elderly

patients by daily exercise.

KAN-182 Mira Yulianti (01-107)

OXIDATIVE STRESS DECREASED ANTIOXIDANT & SCAVENGINGCAPACITY

DAMAGE TOMEMBRANES, PROTEINS,

& GENETIC INTEGRITY

INCREASED INTRACELLULARFREE-RADICALS

INCREASEDSUSCEPTIBILITY TO

DISEASE, INFECTION ANDINJURY

LOSS OF TISSUE ANDORGAN FUNCTIONAL

RESERVE

DECREASEDBIOENERGETIC

CAPACITY

INCREASEDPROBABILITYOF DEATH

ycle of Aging

At a cellular level,(within mitochondria)


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2. Short-term increases in cardiac output are accomplished in the elderlypatient initially by modest increases in heart rate and then by progressivelylarger stroke volume.

3. Aging decreases the inotropic and chronotropic responses to neurallymediated adrenergic stimulation such that maximum heart rate and inotropicresponse are age limited.

4. Passive ventricular filling, which normally occurs during the earlyphase of diastole, is decreased in elderly patients (stiffer and lesscompliant ventricle)

5. Age-related diastolic dysfunction elderly patients more dependenton synchronous atrial contraction for complete ventricular filling.a. VR stroke volume compromiseb. Perioperative arterial hypotension is predictable more common

in elderly than in young6. Systolic arterial hypertension fibrotic replacement of elastic

tissue within the cardivascular system.

B. REPIRATORY FUNCTION Fibrous connective tissue loss of lung elastic recoil (inevitable

emphysema-like changes)1. FRC , VC , Residual Volume

2. Costochondral calcification thorax more rigid WoB3. Age related acute post-operative ventilatory failure4. Age related decrease in arterial oxygenation5. More vulnerable to developing transient apnea when given drug (opioid,

benzodiazepin) post operative.6. The treshold stimulus needed for vocal cord closure risk of

aspiration of gastric content.

IV. hepatorenal and immune functionA.

1. Liver tissue mass decreases about 40% by the age of 80 years, and hepaticblood flow is proportionally decreased.

2. Hepatic metabolism may be age and gender specific.3. Hepatic enzyme activities are unchanged by aging and normal value for

plasma transaminases are unchanged.

B.

1. Renal tissue mass decrease by about 30%, and RBF decreases by about 50%by the eighth decade of life.

2. Serum creatinine concentration usually remains within the normal range.3. Intravascular and intracellular dehydration

C.

1. Elderly patients exhibit decreased immune responsiveness

V. Metabolism, Body Composition, And Pharmacokinetics

A.Aging in men results in a progressive and generalized loss of

skeletal muscle mass and reciprocal increases in the lipid fraction

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BODY BODY LIPIDLIPID

OTHEROTHERTISSUETISSUE

BODY BODY WATERWATER

MENMEN

WOMENWOMEN

YOUNG YOUNG YOUNG YOUNGOLDEROLDER OLDEROLDER

Age related changes in body composition are gender specific. I ncAge related changes in body composition are gender specific. I nc reases in body fat offset bone loss and intracellularreases in body fat offset bone loss and intracellulardehydration in women, whereas in man accelerated loss of skeletadehydration in women, whereas in man accelerated loss of skeleta l muscle and other component of lean tissue massl muscle and other component of lean tissue massproduces contraction of intracellular water and a decrease in toproduces contraction of intracellular water and a decrease in to tal body weight.tal body weight.

Hand book of Clinical Anesthesia:Hand book of Clinical Anesthesia: Barash.PGBarash.PG ,, Cullen.BFCullen.BF ,, Stoelting.RK Stoelting.RK :2001, 654:2001, 654

Aging in men results in a progressive and generalized loss of sk Aging in men results in a progressive and generalized loss of sk eletaleletalmuscle mass and reciprocal increases in the lipid fractionmuscle mass and reciprocal increases in the lipid fraction

V. METABOLISM, BODY COMPOSITI ON, AND PHARMACOKINETI CSV. METABOLISM, BODY COMPOSITI ON, AND PHARMACOKINETI CSA.A.

HasanulHasanul -- 20032003

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 component of lean tissue mass produces contractionof intracellular water and a decrease in total body weight.



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1. BMR , heat production , special risk for intraoperative hypothermia Intraoperative decreases in core body temperature average almost 10C per

hour. The time needed for postoperative spontaneous rewarming may be prolonged.

2. Progressive impairment of the ability to handle an intravenous glucosechallenge

B. Plasma volume, red cell mass, and ECF volumes are normallywell maintained in normotensive elderly individuals who maintain their habits ofdaily physical activity

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

VI. Central Nervous SystemA. Aging decreases brain size, and neurons that synthesize neurotransmitters

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

B. CBF decreases in proportion to decreased brain tissue.1. Autoregulation is well maintained, and the cerebral vasoconstrictor

response to hyperventilation remains intact.2. In the absence of cerebrovascular disease, the conventional guidelines

for controlled hypotension during neurosurgical procedures are appropriatefor elderly.

C. Comprehension and long term memory are well maintained.

D. Hypothalamic-pituitary-adrenal dysregulation and increased plasma cortisollevels.

VII. Peripheral Nervous SystemA. The treshold intensities of stimuli needed to initiate all forms of

perception are increased.B. Aging is associated with a gradual but significant deterioration of

electrical conduction along efferent motor pathway.C. Cholinoreceptors at the skeletal muscle .

VIII. Autonomic Nervous SystemA. Neurons in the sympathoadrenal pathways decline by at least 15% by 80 years of

age. Nevertheless, plasma nor-epinephrine are significantly . Aging markedly and progressively depresses autonomic end organ

responsiveness

Aging produces an endogenous blockade. Aging appears to produce little change in -adrenergic or muscariniccholinoceptor activity.

B. Baroreceptors that maintain cardiovascular homeostasis are progressivelyimpaired

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

IX. Analgesic and Anesthetic RequirementsA. There are decreased segmental dose requirement for local anesthetics duringepidural, and slightly higher levels of sensory blockade undergoing spinal

anesthesiaB. MAC decrease predictably with increasing age.C. Systemic morphine requirements are inversely related to patient age.



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D. Barbiturates, and benzodiazepines are less consistent than those for inhaledanesthetics

E. Doses of muscle relaxants and steady state plasma concentrations required toproduce a given degree of neuromuscular blockade are not changed by aging. Theclinical duration of action is prolonged if the elimination of the musclerelaxant is dependent on hepatic or renal clearance mechanisms

I I I I II I I I I I II I

0 20 40 60 800 20 40 60 80 100 120100 120

DOXACURIUMDOXACURIUM

PIPECURONIUMPIPECURONIUM

METOCURINEMETOCURINE

CURARECURARE

PANCURONIUMPANCURONI UM

CI SATRACURIUMCISATRACURIUM

VECURONI UMVECURONI UM

ATRACURIUMATRACURIUM

ROCURONIUMROCURONIUM

MIVACURIUMMIVACURIUM

RIRI -- OLDER ADULTOLDER ADULT

RIRI -- YOUNGER ADULT YOUNGER ADULT

RECOVERY I NDEXRECOVERY I NDEX

(T(T 2525 -- TT 7575 , minutes), minutes)

RI : Recovery Index , the time required for spontaneous recoveryRI : Recovery Index , the time required for spontaneous recovery fromfrom25% to 75% of the control evoked neuromuscular response.25% to 75% of the control evoked neuromuscular response.

Hand book of Clinical Anesthesia:Hand book of Clinical Anesthesia: Barash.PGBarash.PG ,, Cullen.BFCullen.BF ,, Stoelting.RK Stoelting.RK :2001, 658:2001, 658HasanulHasanul -- 20032003

RI : Recovery Index ,

The time required for spontaneous recovery from 25% to 75% of the control evoked neuromuscularresponse

X. Perioperative Management and OutcomeA. Age-related disease and not aging is primarily responsible for the progressive

increase in morbidity and mortality of elderly surgical patients (see table) Age Related Disease :

Hypertension Ischemic Heart Disease CHF Peripheral vascular disease COPD Renal disease Diabetes Mellitus Arthritis Dementia

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

Drugs Likely to be Taken By Elderly Patients Anti hypertensives Anti depressants Anticoagulants Oral hypoglycemics

Corticosteroids Beta-blockers Sedatives

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

C. The choice of anesthetic drug or technique does not seem to influence theoverall outcome in elderly patients1. Newer intravenous drugs (remifentanil, cisatracurium) minimize dependence on

organ system functional reserve, whereas newer inhaled anesthetics(sevoflurane, desflurane) provide rapid recovery of consciousness even inelderly patients

2. Prompt and complete postoperative recovery of mental function is particularlyimportant in elderly

Less likely to experience nausea and vomiting, but more likely to experiencemental confusion following outpatient surgery compared with young adults.

The most common cause of failure to emerge promptly from anesthesia is toomuch anesthesia or too many anesthetic drugs.



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Nerve palsies due to regional anesthesia seem to occur more often comparedwith younger adults

D. Anesthetic management is appropriate, surgical convalescenceuncomplicated, full return of cognitive function to preoperative levels mayrequire 5-10 days

E. Physical management in OT & RR, require special precautions, gentleand careful positioning

F.

Postoperative bleeding & bacterial infection more likely compared withyoung adults

Diastolic dysfunction, ventricular stiffness, rate of iv.fluid (toofast) may precipitate pulmonary edema

Untreated pain & related emotional stress immune responsiveness


6.anesthesia for the geriatric patient

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