anesthesia and the elderly patient sheila r barnett, md assistant professor anesthesiology harvard...
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Anesthesia and the Elderly Patient
Sheila R Barnett, MDAssistant Professor
AnesthesiologyHarvard Medical School
Beth Israel Deaconess Medical Center
Population
USA
> 65y
>85 y
Surgery > 65 years
Frequency of 12 common procedures
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800
<15 y 15-44 y 45-64 y >65 y
Su
rge
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0 0
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35% of surgeries in USA
16,000,000 surgeries per year
RISK & COMORBIDITIES
Aging involves physiological changes
AND
the pathophysiology of superimposed disease
30 day Surgical Mortality
2nd Qtr 3rd Qtr 4th Qtr27.4 90 20.438.6 34.6 31.646.9 45 43.9
0
1
2
34
5
6
7
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910
30 Day Percent mortality
All ages60 -69y70-79y>80y >90 y
Thoracotomy mortality over 70y: 17% Emergency abdominal surgery > 80y: 10%Major procedure mortality over 90y: 20 %
Jin & Chung Br J Anaesth 2001; 87:604-24
Present later Review of colorectal surgery Outcomes 65-74; 75-84; >85 years 34 194 patients Oldest patients:
Presented later More co morbidities Emergency more common Survival lower
Lancet 2000; 356: 968
Preoperative conditions
0
20
40
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100
544 patients > 70 y. JAGS 2001 49:1080
%
344 high risk CEA patients, mean 72 y. NEJM 2004; 351:1493
Surgery Outcomes
> 70y non cardiac surgery ; prospective 544 patients – age 78y 21% adverse outcome
3.7 % died Adverse outcomes:
CVS 10% CNS 8% Pulmonary 5.5% Renal 2.5% LOS: 9 vs 4 days (p<0.001)
Predictors: Emergency ASA Class
Tachycardia
Preop : Functional status CHF
Leung et al JAGS 2001 49:1080
Long term impact
Follow up 28 months on 517 patients - 32% deceased
With complications: greater 3 month mortality (p 0.02)
Predictors of mortality (p<0.0001) Cancer, ASA>2, CNS disease, Age, & Postop pulmonary and renal complications
Long term quality of life Not impacted by postoperative outcome comorbid conditions, age and new hospitalizations
Manku & Leung Anesth Analg 2003;96:583 -94 (pts 1&2)
80 year old patients 26 648 > 80 y compared to 568 263 < 80 y
30 day mortality all cases 8% vs. 3%, p<0.001 < 2% > 80 y for simple procedures
TURP, IH, TKR, CEA > 80y 20% 1 or more complications 26% mortality in patients > 80 y with
complications vs. 4% if no complication Mortality if > 80y with serious complications >
33%
Hamel et al JAGS 2005; 53:424
General Risk Factors for post operative mortality ASA 3 & 4 Major surgical procedures Disease: Cardiac, pulmonary, DM,
Liver and renal impairment Functional status < 1-4METS Anemia & Low albumin Bed ridden
Pathophysiology of Aging
Cardiovascular Peripheral
Decrease in arterial elasticity – vascular stiffening
Increase in BP Increase peripheral vascular resistance
Ventricular Increased impedance - wall hypertrophy decreased compliance Resting CO unchanged more atrial dependence
Cardiovascular Rate & Rhythm
Conduction issues: Decline in pacemaker
cells, fatty infiltration, fibrosis
Increase in atrial ectopy, sinus and
ventricular conduction defects
Reduction in maximal HR – reduced
response to catecholamines
Increased ischemic heart disease
Cardiovascular Autonomic Function Dysautonomia of Aging
Decline in beta receptor sensitivity HR responses impaired
Increased norepinephrine levels
Altered sympathovagal balance - decreased HRV
Decreased baroreflex sensitivity
Heart Failure
6-10% > 65 heart failure
80% admissions with heart failure are >65 y
40 –50 % of patients with heart failure have normal LVEF
Diastolic Dysfunction
Diastolic Function
Classification
% LVEF
Normal 37% 54%
Mild to Moderate
57.9% 54.5%
Moderate 3.9% 54%
Severe 1.7% 43%Philip Anesth Analg 2003 ; 97 1214-21
251 patients / CAD Age 72 y
Diastolic function : E/A & deceleration time
61.5%
HTN Prevalence
WOMEN
MEN
Hypertension > 50% elderly
Treatment usually > 140/90 mmHg “High normal” 130-139/85-89
mmHg
VA study – Berlowitz NEJM 1998;339:1957
800 males aged 65+/- 9years 40% BP > 160/90 mmHg Despite 6 visits /year
NHANES lll only 29% hypertensive population reach target goal
Complications of HTN
Risk increases linearly with BP“High normal” BP 130-139 / 85-89 mmHg
also increased risk Ischemic heart disease & MI Stroke LVH Diastolic dysfunction & pulmonary
edema Renal failure
Increased Pulse Pressure
Pulse pressure = SBP –DBP
? Possible marker for vascular disease
Low DBP also poor prognosis
Framingham Heart Study1924 men & women Ages 50-79yBP components & CHD risk 20 y f/u
Franklin et al Circulation 1999; 100: 354
CHD risk increased when SBP > 120 and DBP decreased
The ll/VI SEM
Aortic Sclerosis - is it really benign?
>5000 echos 29% (1600) with sclerosis, no
obstruction 5 year f/u
Almost 50% increase in death from CVS causes and MI in sclerosis
Otto et al, NEJM 1999
Pulmonary Function and Aging
Thorax stiffens – reduced chest wall compliance &
decreased thoracic skeletal muscle mass = Increased work of maximal breathing
Lung volumes change – reduced inspiratory and expiratory reserve volume
Decrease in elastic lung recoil –closing volume increase
Aspiration Risk
Reduction pharyngeal sensation
Reduction of maximal NIP
Swallowing coordination may be diminished
Central Nervous System
Cortical grey matter attrition – starts in middle age
Cerebral atrophy – disease vs. aging
Increased intracranial CSF
CBF and auto regulation largely maintained
CNS deficiencies Neurotransmitter deficiencies Integration of neuronal circuits Fluid intelligence
Spinal cord demyelination Decreased spinal reflexes
Peripheral nervous system Fibrosis in peripheral nerves
Less myelinated fibers
Slower nerve conduction
Diminished muscle mass
CNS & Drugs Pharmacodynamic MAC Altered respiratory drive & drugs
Spinal drugs Epidural spread sensitivity
Cognitive Dysfunction Post operative delirium
Cognitive dysfunction:non-cardiac surgery
Post cardiac surgery
Post-operative delirium
Incidence 10-15% in >65y
Increased mortality Longer hospital stay Numerous risk
factors: Advanced age Dementia, Depression Anemia
Alcohol and drug withdrawal Metabolic derangement Acute MI Infection Emergency surgery
Delirium costs! Per year over 2.3 million older
people have delirium during hospital stay
17.5 million inpatient days
>$ 4 billion (1994 #s) Medicare expenditure
Inoye NEJM 1999; 340:669
1218 patients >60 years Early 7 days 26% Late 3 months 9.9% (controls 2.8%)
Early Increasing Age Duration anesthesia Low education Second operation Infections Respiratory Complications
Late Age only
Moller et al Lancet 1998
Postoperative Cognitive Dysfunction
RCT: 262 patients Knee replacement – epidural vs. general 5% clinical deterioration in cognitive
status at 6 months No difference GA vs. regional Early delirium may be marker for ongoing
cognitive deterioration
Many similar trials and results …(but fractures & joint replacements – apples and oranges?)
Williams Russo et al JAMA 1995; 274:44
Is it the Anesthetic?
Confusion – what can you do?
Quick baseline assessment – date, year etc
Days of the week backwards Honest informed consent to patient and
family members Careful drug (and ETOH) history Avoid polypharmacy Pain control
Mild Cognitive Impairment “Transitional state between the cognitive
changes of normal aging and the earliest clinical features of Alzheimer's disease”
10 -15% will develop Alzheimer's in a year
1-2% normal elderly – Alzheimer’s
Role of genetics and Apolipoprotein E 4 alleles
Petersen et al NEJM 2005; 352:2379
Vascular patients
Longitudinal study – 11 years 4141 men & 1681 women Cognitive testing Poor cognitive function
Independent of age or SE class Angina p 0.001 MI p 0.02 Claudication p.004
Singh-Manoux JAGS 2003; 51:1445
Should we do more? Informed Consent ?
Hospitalization “unmask” marginal cognitive function
Dementia prevalent
Postoperative rehabilitation plans
Cognitive Preoperative Assessments?
Renal Function
Progressive decrease in Renal Blood flow
Renal tissue atrophy - primarily cortical 30% reduction in nephrons age by middle
age Sclerosis reaming nephrons
Glomerular filtration rate declines
Serum creatinine misleading – ‘occult’ renal insufficiency
Fluid homeostasis Sodium conservation impaired Urine concentrating ability reduced Thirst diminished
Post operative Acute Renal Failure >50% mortality in very elderly patients
Body Compartments
Decline in total body water intracellular water plasma volume maintained
Less lean tissue & skeletal muscle mass
Increase proportion of fat
Hepatic Decrease in hepatic mass
Decrease in hepatic clearance
Less albumin
Qualitative change in protein binding
Alpha-1-glycoprotein increases
Drug considerations water soluble drugs
prolonged half life of lipophilic drugs
decreased hepatic metabolism& renal clearance
increased target organ sensitivity
Risk – What Dose?
Summary pathophysiology
Steady decline in organ function
Unpredictable reserve function
Increased comorbidity
Reserve Function Diminished
Risk Reduction Beta Blockade Comprehensive assessments Less invasive surgery ? Regional
Beta Blockade & Risk Reduction
Mangano NEJM 1996;335:1713
100/200 patients received Atenolol preop and for 7 days
Atenolol group improved survival 6 months & up to 2 y. Diabetes major risk
Wallace Anesth 1998;88:7
Atenolol reduced postoperative ischemia by 30- 50%
High risk vascular patients with positive dobutamine echocardiograhpy. Mean age 68y 173/ 846 positive echos
59 bisoprolol 61 excluded on Beta blockers /wma 53 standard care (SC)
Bisoprolol vs SC death or non fatal MI:
2 (3.4%) vs 18 (34%) Poldermans NEJM 1999;341:1789
Beta blockers continued …
> 600 000 patients undergoing non cardiac surgery
18% received perioperative beta blockade
Reduction in death for those with a Cardiac Risk Index Score of 2-4
But possible increased risk of death for those with Cardiac Risk Index of 0 or 1
Lindenauer et al NEJM 2005; 353:349
Beta Blocker Prescription after AMI by Age
0
10
20
30
40
50
60
45,370 patients eligible for beta blockade
Vitagliano et al. JAGS 2004: 52:495
Beta Blockers & the Frail
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Pe
rce
nta
ge
Be
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ers
I II III IV
Frailty Stage
Vitagliano et al. JAGS 2004: 52:495
Comprehensive Geriatric Assessments (CGA)
120 patients >60 y CGA
ADLs, IADLs (Barhtel Index) , comorbidity, nutrition, MMSE
All undergoing thoracic surgery 17% post op complications Predictors –
Low Barthel Index Surgery >300 mins Dementia – low MMSE
Fukuse Chest 2005; 127:886
Intervention Program to Reduce Delirium 400 patients > 70 y Admitted to Intervention Ward
Assessment, prevention treatment education Assessment day 1,3,7 Delirious patients in the Intervention ward
Shorter duration: by day 7 30% vs 60% (p 0.001 ) Shorter LOS: 9 vs 13 days (p 0.001) Reduced mortality: 2 vs. 9 patients died (p 0.03)
Lundstrom et al JAGS 2005:53:622
Less invasive surgery ? CEA
344 high risk patients average 72 y Stent vs. open Results showed stent as good –
possible reduction in death at 1 year and at least as good or less adverse events
Endovascular AAA 1 year perioperative survival advantage
vs. open
Yadav et al NEJM 2004; 351:1493
Blankenstein et al NEJM 2005; 352:2398
Spinal or Epidural vs. General Anesthesia
Long a source of controversy Expert opinion suggesting no significant
difference in major complications or mortality
Meta-analysis of 141 randomized trials Total of 9559 patients Studied neuraxial blockade (either spinal
or epidural anesthesia) vs. general anesthesia
BMJ 2000;321:1
Rodgers et al BMJ 2000; 321:1-12
Meta-Analysis of Neuraxial Blockade vs. General Anesthesia
Perioperative event Odds reduction for
neuraxial blockade
Death 30%
DVT 44%
Pulmonary embolism 55%
Pneumonia 39%
Respiratory depression
59%
Myocardial infarction 33%
Rodgers et al BMJ 2000; 321:1-12
Fractures too… Meta analysis 15 randomized trials 2162
patients In Spinal:
Reduction in 1 month mortality (6% vs 9%)
Reduction in DVT
Future – epidural vs LMWH and other anticoagulant strategies
Urwin et al Br J Anesth 2000; 84(4) 450-455
Cataracts
Low risk High volume High comorbidity
Do you ever wonder why we are in the room?
1999 Survey in USA 45% Ophthalmologists using topical
Rosenfeld in 1999 1006 patients 33% needed an intervention during surgery No predictive factors
International Studies 78% anesthesiologist present But low topical rate
Reeves survey ‘net preference’ for anesthesiologists
Stein et al; NEJM 2000; 342: 168
Routine Preoperative Testing before CataractSurgery
R o utine T e sting 9 4 08 P a tie n ts
N o T e sting9 4 11 P a tie n ts
1 8 1 8 9 C ata rac t p a tie n ts
Preoperative Medical Assessment
No tests unless new or worsening condition
EKG; CBC; Lytes, BUN, Creat & Gluc
No Testing Routine Testing
Both groups intra and postoperative medical events 3.1/ 1000 operations
“Routine medical testing before cataract surgery does not measurably increase the safety of the surgery”
But… Preoperative evaluation done in ALL
patients and ALL patients had opportunity to have testing
Conclusion Testing should directed by history and
physical performed prior to surgery
The Hip Fracture A Morbid Event
Is the hip fracture the sentinel event marking deterioration ?
Hip fractures 300 000 hospitalizations 1 year mortality 25% - reduction life
expectancy Attributable cost of fracture $81 300 Disability significant M & M US in 1997 > $20 Billion
Braithewaite JAGS 2003; 51: 364
Hip fractures, old people and the inevitable …..
Hip fractures have high perioperative mortality 10 -25%
Why? 300 unselected hip fractures All received similar multimodal
treatment Anesthesia epidural / strict protocol Well defined rehabilitation
Foss & Kehlet 2005; Br J Anaesth 94; 24-9
30 day mortality =13% ; >30 days 7 more died
Combined mortality=16%
Analysis of 47 deaths 28% (13) unavoidable: terminal cancer, refused
care 15% (7) probably unavoidable 34% (16) potentially avoidable; active care
curtailed 23% (11) Maximum care; ? avoidable
Why did they die? Foss & Kehlet 2005; Br J Anaesth 94; 24-9
Miscellaneous
Sensory Changes Decreased visual acuity & dark adaptation
Attrition of taste buds
Diminished thirst sensation
Compromised joint perception
Diminished fine control of skeletal muscles
> 80y
DISABILITIES COMMON
Polypharmacy
Adverse drug events 3 -10% admissions common
Elderly on multiple medications 30% prescriptions & 40% of OTC
drugs
Drugs and herbs eg Ephedra alkaloids -ma huang Adverse Events : HTN, palpitations,
strokes, seizures
ETOH & Elderly Alcohol and Drug prescription problems
affect 17% of older Americans
Increase sensitivity & decrease in tolerance
Decrease lean body mass & TBW = higher concentration
Decrease in alcohol dehydrogenase may slow metabolism
Social Issues
Increase in disability
Lack of a spouse
Cognitive and sensory problem Scheduling - a family commitment
Challenges & Elderly
heterogeneous population
unpredictable organ reserve
disease burden
atypical disease presentation
emergent procedures
minor complications can rapidly
escalate
Geriatric Graphs
Age years Function
Age years
Disease or
badness
Future ? Cognitive Preoperative assessment
Functional outcomes
Perioperative interventions