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SPECIAL ARTICLES

Anaesthesiology Intensive Therapy

2013, vol. 45, no 2, 5761

ISSN 16425758

DOI: 10.5603/AIT.2013.0013

www.ait.viamedica.pl

Guidelines for general anaesthesia in the elderlyof the Committee on Quality and Safety in Anaesthesia,

Polish Society of Anaesthesiology and Intensive Therapy

Radosaw Owczuk

Department of Anaesthesiology and Intensive Therapy, Medical University of Gdansk, Poland

The prolongation o the human liespan, one o the most

important achievements o modern medicine, has led to

a rapid increase in the number o elderly people (according

to the current denition, this reers to those over 65 years

o age). The incidence o anaesthesia and surgery in elderly

patients is assumed to be our-old higher compared to the

remaining general population [1]. It is estimated that within

the next ten years the demands or invasive procedures

will increase by 25%, whereas the geriatric population will

grow by about 50% [2]. Consequently, the demands or

anaesthesia in the elderly will increase.

Elderly people require specic management adjusted

to the natural processes o ageing, higher prevalence o co-

-existing pathologies, and dierent responses to medicines

used in the perioperative period. The pathophysiological

changes associated with natural ageing aect all the organs

and tissues, especially those in the cardiovascular, respirato-

ry, urinary and central nervous systems. At a rough estimate,

the competence o internal organs diminishes by 1% per

one year o lie over the age o 40 [3].

RISK ASSESSMENT

The decision concerning surgery and anaesthesia should

not be solely based on a patients age; the risk-benet ratio

ought to be assessed. Four main independent risk actors

are considered the indicators o possible risk o surgery in

patients over the age o 65: age, general condition and coexi-

sting illnesses (according to the ASA scale), urgency o surge-

ry (scheduled or emergent), and type o surgical procedure.

Advanced age is a risk actor o possible anaesthetic

complications and major incidents in the post-surgery recu-

peration period [4]. It should be stressed, however, that age

itsel is responsible only or a slight increase in anaesthetic

complications, which are much more related to the urgency

o surgery and severity o other systemic diseases [2, 5].

PATIENT PREPARATION FOR ANAESTHESIA

The success o anaesthetic and surgical procedures de-

pends not only on proper and skilul perormance, but also

on suitable preparation o patients or surgery and anaesthe-

sia, and in particular patients with concomitant diseases.

1. In scheduled procedures, preparation or anaesthesia

should be started early.

2. Strategies to reduce surgery-related cardiovascular com-

plications using -adrenolytics, statins or angiotensin

convertase inhibitors should be optimally introduced

our weeks prior to anaesthesia (seven days as a mini-

mum) [2]; thereore, co-operation between the hospital

personnel and GPs as well as early patient visits to the

anaesthesiological outpatient clinic are required.

3. In cardiovascularly compromised patients, preparation

or surgery/anaesthesia and optimisation o the patients

condition should be consistent with the guidelines o

the European Society o Cardiology and European So-

ciety o Anaesthesiology [2].

4. Optimisation o the patients condition and preparation

o patients with severe chronic diseases should be based

on co-operation with a suitable specialist.

ADDITIONAL TESTS CONDUCTED PRIOR

TO ANAESTHESIA

In the majority o cases, the ollowing tests are recom-

mended:1. Peripheral blood tests, including lymphocyte count (to

evaluate potential malnutrition).

Accepted by members of the Commitee on Quality and Safety

in Anaesthesia, Polish Society of Anaesthesiology and Intensive Therapy:

Janusz Andres (Krakw), Wojciech Gaszyski (Lodz),Przemysaw Jaowiecki (Katowice), Krzysztof Kusza (Bydgoszcz),

Andrzej Nestorowicz (Lublin), Ewa Mayzner-Zawadzka (Olsztyn)

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Anaesthesiol Intensive Ther 2013, vol. 45, no 2, 5761

2. Serum concentrations o sodium, potassium, chlorides,

urea and creatinine.

3. Fasting blood sugar.

4. Resting 12-lead ECG.

5. Chest X-ray.

In individual cases, it is necessary to widen the spectrum

o tests and consultations, depending on the kind and se-

verity o diseases.

Since the muscle mass in the elderly decreases, the renal

unction should be assessed based on serum concentrations

o creatinine and urea as well as renal ltration, which is best

determined by the Cockrot-Gault ormula [6]:

Creatinine

clearance=

[140 age (years)] body mass (kg) C

Serum creatinine (mg dL1) 72

C constant: women = 0.85; men = 1.0.

CONSENT FOR ANAESTHESIA

According to the Medical and Dental Practitioners Act,

the patient should give conscious and voluntary inormed

consent or any medical procedure, including anaesthesia.

In cases o patients incapable o providing such consent due

to quantitative or qualitative consciousness decits, the con-

sent is given by the statutory representative or, in his or her

absence, by the Guardianship Court with jurisdiction over

the place o procedure. It should however be remembered

that i the patient is legally incapacitated, but still able to

consciously communicate his or her will, it is necessary to

obtain an additional consent rom him or her [7].

PREMEDICATION

The available literature does not prove beyond all doubt

that routine premedication is benecial to elderly patients

[8]. Any decision-making concerning administration and

type o premedication in this age group should consider

the ollowing actors:

1. The decision regarding pharmacological premedication

ought to be made on an individual basis, taking into

consideration the physical and psychological condition

o the patient, possible side eects o administered

medicines and their interactions with the drugs already

used by the patient or chronic conditions.

2. Possible premedication-related side eects should be

taken into account, especially paradoxical stimulation

and impaired respiration or circulation (monitoring sho-

uld be provided in the patient's ward).

3. Extremely anxious patients can receive an anxiolytic

(usually a short-action benzodiazepine).

4. Midazolam should be used with great caution due toincreased risk o respiratory depression or arrest, even

at very low doses.

5. In highly aroused patients, oral olanzapine or a small

dose o lorazepam may be considered [9].

6. Since the patients reactions, even to reduced doses o

premedication agents, are unpredictable, enhanced

surveillance ater their administration and during trans-

port to the surgical ward is required.

During the pre-surgery visit, the physician should discuss

not only possible premedication, but also pre-surgical liquid

supply, especially in patients who are not anaesthetised and

operated on rst. There are no contraindications or small

amounts o clear liquids 23 hours prior to anaesthesia,

unless patients suer rom severe diabetes and/or chronic

renal ailure, due to gastropathy that accompanies such

conditions.

INDUCTION OF ANAESTHESIA

Induction o anaesthesia in elderly patients can be par-

ticularly dicult during general anaesthesia. Patients over

65 years o age display high variability in their responses

to induction drugs especially i.v. anaesthetics. Compared

to the younger population, the doses should be lower due

to decreased volume o distribution [1]. It is recommended

to monitor meticulously the patients cardiac parameters

during induction.

1. Due to decreased unctional residual capacity, the pre-

oxygenation period should be longer.

2. Doses o opioids used or induction (entanyl, suentanil)

do not have to be reduced considerably compared to

the doses administered to younger patients [8]. Never-

theless, the utmost care should be taken during admini-

stration o remientanil or the initial dose o remientanil

abandoned due to the risk o circulatory depression and

chest wall rigidity.

3. The Polish Society o Anaesthesiology and Intensive The-

rapy recommends inhaled induction in elderly patients

[11]. Sevofurane is particularly suited or inhaled induc-

tion and it is well tolerated by elderly patients [1214].

4. Irritation o the airway caused by desfurane signican-

tly limits its use in anaesthesia induction. Desfurane

should not be used or induction in patients with in-

creased risk o ischaemic heart disease or in any cases

where increased heart rate and blood pressure are

contraindicated.

5. The slightest circulatory depression is observed ater i.v.

etomidate; however its administration (as with that o

ketamine) should be careully considered, especially in

patients with circulatory instabilities.

6. Doses o thiopental and propool used in anaesthetic

induction should be decreased by 3040% in compari-

son to those used in younger patients.7. Intravenous anaesthetic titration appears to be the opti-

mal method o administration to obtain the required

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clinical eect (e.g. suppression o eyelash refex) or su-

itable BIS value at the lowest dosage possible.

8. The onset o action o non-depolarising muscle relaxants

is delayed in elderly patients, so lung ventilation via a a-

cemask may have to be provided or a longer time [3, 15].

9. When suxametonium is used, its reduced doses are not

required. In patients with low cardiac output, the onset

o drug eects may be delayed. Even though the activity

o butyrylcholinesterase is decreased in elderly patients,

the clinical ndings do not show prolonged block ater

this depolarising agent [16].

In addition to correct selection o all the agents and

pharmaceuticals used or anaesthesia induction, it is neces-

sary to consider the problems that may be associated with

lung ventilation via a acemask and laryngeal intubation.

Decreased mobility o the cervical spine may hinder opti-

mal head placement. In patients with severely obstructed

cervical arteries, and whose cerebral circulation is mainly de-

pendent on the blood fow via the spinal arteries, excessive

head movements should be avoided. Special care must be

taken during laryngeal intubation in patients with moving

or shiting teeth.

The use o a laryngeal mask and other supralarynge-

al airway devices in elderly patients is an alternative sae

method o securing the airways, unless there are specic

contraindications [17]. Compared to propool, sevofurane

used or anaesthesia induction beore the placement o

a laryngeal mask has been demonstrated to reduce the risk

o adverse circulatory eects and apnoea [18].

MAINTENANCE OF ANAESTHESIA

Maintenance o anaesthesia, as with its induction, re-

quires proper adjustment o drug doses to the patients

age and biological condition. The optimal solution inclu-

des anaesthesia depth monitoring (using BIS or entropy)

and administration o the smallest doses that will maintain

the required anaesthesia level with the proper circulatory

unction preserved. It is estimated that a BIS level o 50

60 is optimal or maintaining anaesthesia in the elderly,

compared to that o about 45 which is optimal or younger

patients [6, 19].

1. It appears that anaesthesia maintenance with inhaled

sevofurane, desfurane or isofurane is optimal or el-

derly patients. Moreover, halogen inhaled anaesthe-

tics enable continuous monitoring o anaesthetic end-

-expiratory concentration and have possible protective

eects on vital organs, especially the heart, which results

in decreased perioperative mortality and morbidity [20].

2. MAC and MAC-awake o halogen agents drop by 45%

or every decade o lie over the age o 40, thus theirconcentrations should be adjusted to the patients age

[21, 22].

3. A sudden increase in desfurane concentration in the

inhalation mixture should be avoided due to the risk o

sympathetic nervous system stimulation and resultant

elevated arterial blood pressure and increased myocar-

dial oxygen demand.

4. Desfurane should not be administered to patients with

obstructive diseases (e.g. chronic obstructive pulmonary

disease, asthma) as it can result in bronchospasms.

5. Nitrous oxide should be used or anaesthesia main-

tenance with due caution in patients with impaired

circulatory unction, as its cardiodepressive eects are

likely to decrease arterial blood pressure [3].

6. The maintenance dose o propool should be adequate

to the dose used or anaesthesia induction. The dose is

usually decreased by 50% compared to the maintenance

dose used in younger patients. I the inusion guided by

target concentration is used, the Schniders model, taking

into account the patients age, is recommended [23].

7. The remientanil dose used in inusion should be redu-

ced to 3040% o the dose used in younger patients

due to increased risk o cardiovascular complications,

resulting rom the small volume o distribution o this

opioid, decreased clearance and increased susceptibility

o elderly patients.

8. It is recommended to reduce the doses o other opioids by

4050% compared to the doses used in young patients.

9. Pharmacokinetics o atracurium and cisatracurium does

not change with age, so there is no need to adjust the

dosages. Decreased metabolism o pancuronium, vecu-

ronium and rocuronium is likely to prolong their time

o action [3, 4].

SPECIFIC INTRAOPERATIVE PROBLEMS

1. Elderly patients are more prone to intraoperative hypo-

thermia that increases hospital morbidity and mortality.

Thereore, some preventive measures are required (ma-

intaining proper temperature in the operating room,

patient warming, inusion fuid heating).

2. The strategy o intraoperative fuid therapy based on

administration o balanced fuids should be tailored to

a particular surgical procedure and the patients con-

dition, and to a lesser degree to the patients age [8].

3. The decision to transuse red blood cells or otherwise

should be based on the assessment o myocardial ischa-

emia-related clinical symptoms, including haemodyna-

mic instability, tachycardia or ECG changes. The haemo-

globin concentration and peripheral blood haematocrit

are insucient to make such a decision. Moreover, deter-

minations o haemoglobin oxygen saturation in mixed

venous or superior vena cava blood may prove useul.4. Special procedures, such as controlled hypotension or

normovolemic haemodilution should be used with great

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caution due to possible disturbances in autoregulation

o blood fow in some vital organs resulting in their

ischaemia and secondary ailure.

ANAESTHESIA WITHDRAWAL

The altered physiological conditions, as well as die-

rent pharmacokinetics and pharmacodynamics in elderly

patients, can prolong their recovery rom anaesthesia even

at reduced doses o anaesthetics; in some cases articial

lung ventilation is required in the immediate postoperative

period.

One o the most important problems o the aoremen-

tioned postoperative period is the restoration o proper

neuromuscular junction unction and prevention o resi-

dual paralysis that may cause postoperative pulmonary

complications.

1. It is recommended to use intraoperative monitoring o

the neuromuscular blockage level and to extubate the

trachea ater it has ully subsided.

2. Acetylcholinesterase inhibitors may be saely used in

elderly patients. However, their adverse eects must be

taken into account. Moreover, it should be remembered

that administration o ACE inhibitors and obligatory

atropine might induce postoperative cognitive disorders

and conusion.

3. Reversal o rocuronium-induced neuromuscular block

with sugammadex appears preerable, but this method

is not recommended or patients with renal insu-

ciency [24].

All elderly patients ought to be meticulously observed

and closely monitored in recovery rooms and postoperative

care units.

POSTOPERATIVE PAIN MANAGEMENT

Postoperative pain treatment is a challenging task, due

to a smaller saety margin o analgesics and diculties in

pain assessment associated with patient conusion and

age-related nociceptive disorders.

1. Postoperative pain assessment using routine scales may

be dicult or even impossible in some elderly patients.

2. It is recommended to use specic methods o pain as-

sessment based on observation o patients at rest and

on movement (e.g. the MOBID Scale Mobilisation

Observation Behaviour Intensity Dementia) [25, 26].

3. The detailed principles o postoperative pain manage-

ment should be based on inormation ound in geriatric

anaesthesia and pain medicine handbooks [27, 28].

SPECIFIC POSTOPERATIVE PROBLEMS

Patients over the age o 65 are at a particularly high risko postoperative conusion (delirium) and cognitive disor-

ders (PCD Postoperative Cognitive Dysunction) [29, 30].

CONFUSION

1. Frequency o conusion incidents ranges rom 35% to

70% ater some procedures.

2. An extremely high risk o PCD is associated with mi-

dazolam.3. The other risk actors include hypoxia, anticholinergic

drugs, impaired metabolism o sodium and potassium,

abnormal glucose levels, alcohol abuse, inections, de-

hydration, sleep, visual and auditory disorders.

4. In such cases, the risk actors should be early identi-

ed, reversible causes treated and pharmacotherapy

administered (haloperidol or other neuroleptics such

as olanzapine or risperidone; in some cases, lorazepam

although with caution).

COGNITIVE DISORDERS

1. Cognitive disorders develop during the postoperative

period in about 25% o patients over the age o 65.

2. The most common risk actors are hypoxia, hypotension,

general anaesthesia, increased perioperative stress, glu-

cocorticosteroids and drugs aecting the cholinergic

system.

3. It is essential to avoid situations and drugs that are risk

actors o PCD.

The guidelines presented in this paper set out the ge-

neral rules o anaesthesia in elderly patients. In cases o

age-specic diseases, the guidelines published in geriatric

anaesthesiology handbooks [3, 31, 32] and papers [9, 16,

3335] are recommended. The above guidelines do not co-

verperineural anaesthesia and its useulness in the elderly.

Furthermore, monitored anaesthesiological supervision,

sedation and analgosedation have not been considered.

All these complex issues should be urther analysed and

suitable guidelines designed.

CONFLICT OF INTEREST

This work was supported by AbbVie Poland.

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Corresponding author:

Radosaw Owczuk, MD, PhD

Department of Anaesthesiology and Intensive Therapy

Medical University of Gdansk

ul. Dbinki 7, 80211 Gdask, Poland

e-mail: r.owczuk@gumed.edu.pl