![Page 1: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/1.jpg)
Sheila Ryan Barnett, MD Associate Professor of
AnesthesiologyHarvard Medical School
Beth Israel Deaconess Medical Center
Boston, MA
![Page 2: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/2.jpg)
Population
USA
> 65y
>85 y
![Page 3: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/3.jpg)
16,000,000 surgeries per year
60% of patients of general surgeons > 65y
Growth in specialty surgery expected: 35-47%
Frequency of 12 common procedures
0
100
200
300
400
500
600
700
800
Surge
ry pe
r 100
00
proce
dures
![Page 4: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/4.jpg)
Li et al Anesthesiology 2009; 110: 698-9 US 1999 – 2005
![Page 5: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/5.jpg)
Aging & comorbidities Medications – modifications Medications – to avoid Risk reduction Inevitability
![Page 6: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/6.jpg)
Aging involves physiological changes
AND
The pathophysiology of superimposed disease
![Page 7: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/7.jpg)
Steady Age-related Decline in Organ
Function
![Page 8: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/8.jpg)
![Page 9: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/9.jpg)
> 80y
DISABILITIES COMMON
![Page 10: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/10.jpg)
What is your elderly patient’s functional reserve?
Goal of the preanesthetic assessment
Minor complications poorly tolerated
![Page 11: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/11.jpg)
Vascular stiffening, HTN, loss elasticity Ventricular
• Increased impedance - wall hypertrophy • decreased compliance, atrial dependence
Conduction issues: • Decline in pacemaker cells, increase in atrial ectopy,
& conduction defects Reduction in maximal HR –
• reduced response to catecholamines Increased ischemic heart disease
![Page 12: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/12.jpg)
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
Diastolic E/A : deceleration time / 250 pts /72 y
61.5%
![Page 13: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/13.jpg)
Thorax stiffens:• reduced chest wall compliance & decreased thoracic
skeletal muscle mass = Increased work of maximal breathing
Lung volumes change – reduced reserve volume Decrease in elastic lung recoil – closing volume
increase More V/Q mismatch & greater P(A-a) O2 gradient
Reduction in hypoxic and hypercarbic drive
Increased narcotic-induced apnea Decreased pharyngeal reflexes - ? More aspiration
![Page 14: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/14.jpg)
At age 80 paO2 is about 58 mmHg !
Close to the edge at the start !
![Page 15: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/15.jpg)
• Case controlled study of Spinal surgery patients
• Compared patients with & without Surgical Site Infection (SSI)
• Independent risk factors: – Long surgery OR 4.7 p<0.001– ASA 3 + OR 9.7 p< 0.001– Obesity 4.0 p<0.01– Intraoperative oxygen <50% OR 12 p <0.001
• Potential impact for elderly ?
Maragakis Anesth 2009; 110:556-62
![Page 16: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/16.jpg)
Cortical grey matter attrition – • starts in middle age
Cerebral atrophy – disease vs. aging
Increased intracranial CSF
CBF and auto regulation largely maintained
Postoperative cognitive dysfunction
![Page 17: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/17.jpg)
1. Appreciate reduction in reserve function
2. Understand age related organ changes and the impact of common disease
3. Beware of ‘under-diagnosis’ e.g. DHF & fluids
4. Provide supplemental extra oxygen, (increased risk hypoxemia)
![Page 18: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/18.jpg)
![Page 19: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/19.jpg)
Dose reduction • Pharmacokinetic • Pharmacodynamic
Interval extension
![Page 20: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/20.jpg)
Anesthesiology 2009; 110:1050-1060
![Page 21: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/21.jpg)
What Dose?
Dose response curve flattened in the elderly patient
![Page 22: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/22.jpg)
JR Jacobs et al Anesth Analg 1995; 80:143
25 -50% reduction
![Page 23: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/23.jpg)
50% reduction in initial doses for fentanyl
Significant decrease in pharmacodynamic response
All opioids increased risk apnea & hypercapnia
![Page 24: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/24.jpg)
Increased & delayed hemodynamic impact leading to hypotension
![Page 25: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/25.jpg)
Anesthesiology 2009; 110:1050-1060
![Page 26: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/26.jpg)
“Start low, go slow” Benzodiazepines
• Low dosing with Midazolam to start Opioids
• Beware respiratory depression• Titrate to effect
Reduce inhalation agent Complete reversal of muscle
relaxants
![Page 27: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/27.jpg)
• Anticholinergic side effects – Central: Falls, delirium, cognitive dysfunction– Peripheral : Dry mouth, constipation, confusion
• Anticholinergic Risk Scale – List of drugs with varying anticholinergic
properties – Avoid or limit use if possible
• Beers Criteria – Long acting Benzodiazepines– Multiple medications , many with
anticholinergic properties
![Page 28: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/28.jpg)
• High risk 3 points – Atropine products – Hydroxyzine (Atarax or Visteril) – Diphenyhydramine (Benadryl)– Promethazine (Phenergan)
• Intermediate 2 points – Prochlorperazine (Compazine)
• Low 1 point – Haloperidol– Metoclopramide ( Reglan)
Rudolph Arch Int Med 2008; 168:508-13
![Page 29: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/29.jpg)
Active metabolites normeperidine • Renal excretion• T ½ 14-21 hrs in elderly up to 30 hrs with CRI
Causes myoclonus, twitching and seizures
Associated with delirium in elderly Not recommended: use of meperidine
in patients 75 yrs or older for analgesia is considered indicator of poor care by the Assessing Care of vulnerable elderly.
![Page 30: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/30.jpg)
• Survey of 3000 community dwelling 57-85 y – 81% minimum of 1 prescription drug (PD)– 49% used dietary supplements – 29% used at least 5 PDs
• Among PD users 46% also used over the counter drugs
• 4% at risk of major drug interaction, half with non prescription drugs
• Anti-coagulants most commonly involved
Unknown true impact on the perianesthetic course
Qato JAMA 2008; 300 (24) 2876
![Page 31: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/31.jpg)
1. Avoid meperidine, long acting muscle relaxants & benzo’s and anticholinergic
2. Look for Polypharmacy
![Page 32: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/32.jpg)
Timing of surgery Comprehensive preoperative
assessments Beta Blockade … again
![Page 33: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/33.jpg)
Meta-analysis of >250,000 hip fx pts
Mortality at 30 days and 1 year
When delayed over 48 hours • 41% increase 30 d mortality • 32% all cause mortality
How practical is this?
Shiga et al Can J Anesth 2008; 55:3; 146-154
![Page 34: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/34.jpg)
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
![Page 35: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/35.jpg)
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
![Page 36: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/36.jpg)
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
But later data mixed results with increased stroke and mortality
![Page 37: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/37.jpg)
• Observational study
• 5158 THR/THR patients– 19% Beta blockers
• BB for 7 days (740) • BB DOS & d/c’ed (252) 25%
– No BB (4166)
• Total 1.5% (77) had POMI • BB continued -22 POMI; 7 deaths• BB discontinued -20 POMI; 19 deaths• No BB – 35 POMI; 28 deaths
• Event rate 3% BB vs. 7.9% for d/c’ed BB• In those discontinued beta blockers 2 fold increase in
POMI and death ( OR 2.0)
Van Klei et al Anesthesiology 2009; 111:117-24
![Page 38: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/38.jpg)
0
10
20
30
40
50
60
45,370 patients eligible for beta blockade
Vitagliano et al. JAGS 2004: 52:495
![Page 39: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/39.jpg)
1. Careful preoperative assessment is a priority
2. Get to the OR in a timely manner 3. Risk reduction medication – possible
beta blockers 4. Role of blood transfusions (not
discussed)
![Page 40: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/40.jpg)
Unanticipated day of surgery deaths – > 800 000 patients NSQIP - Death rate 0.08% – Older age 60 vs. 67y and males P<0.0001
• Complications increased death rate
• PACU/ICU transfer most unstable
• Opportunity to improve in 31% (chart review )
• Improvement: hypovolemia, MI and transport period
Bishop Anesth Analg 2008 107: 1924-35
![Page 41: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/41.jpg)
Veterans Hospital Data • 26 648 > 80 y• 568 263 < 80 y
30 day mortality 8% vs. 3%, p<0.001 <2% if > 80y undergoing simple procedures
• TURP, IH, TKR, CEA 20% had complications in > 80y Once a complication – 26% vs 4% mortality
Hamel et al JAGS 2005; 53:424
![Page 42: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/42.jpg)
Cardiac events post non cardiac surgery
7700 patients, 83 (1%) Cardiac event 9 independent predictors In patients experiencing a cardiac
event, intraoperative data more likely to show episode of hypotension +/- tachycardia
Kheterpal et al Anesthesiology 2009; 110:58-66
![Page 43: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/43.jpg)
Avoid complications Hemodynamics
![Page 44: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/44.jpg)
Turrentine et al J Am Coll Surg 2006; 203:865Surgical morbidity
Surgical mortality
![Page 45: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/45.jpg)
300 unselected hip fractures All received similar multimodal
anesthesia & defined rehabilitation Outcomes:
• 30 d mortality 13% • >30d 7 more died
Combined mortality 16%
Foss & Kehlet Br J Anaesth 2005; 94: 24-29
![Page 46: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/46.jpg)
47 deaths • 28% (13) unavoidable, terminal cancer
or refused care • 15% (7) probably unavoidable• 34% (16) potentially avoidable ; active
care curtailed• 23% (11) received maximal care ?
Potentially avoidable
![Page 47: How to best minimize the effects of anesthesia in the elderly and very elderly patients](https://reader035.vdocument.in/reader035/viewer/2022062321/5681419b550346895dad8014/html5/thumbnails/47.jpg)
Best outcomes if:
Avoid complicationsPreoperative optimization OR without delay (when feasible) ? Beta blockers / transfusions Age appropriate drug dosing Postoperative: pain meds, oxygen