Anesthesia for the Older Patient




Quality of evidence

Strength of recommendation

Diphenhydramine, meclizine

Clearance reduced, risk of confusion

Avoid, except in for the use of diphenhydramine for allergic reaction



Atropine, scopolamine

Uncertain effectiveness





High risk of CNS effects, bradycardia, orthostasis

Avoid as first line antihypertensive



First and second generation antipsychotics

Increased risk of stroke and greater rate of cognitive decline, avoid for behavioral problems (including delirium) unless nonpharmacologic interventions have failed and patient is a harm to self or others




Lorazepam, Diazepam

Elderly have increased sensitivity to benzodiazepines and decreased metabolism of longer acting agents





Minimal improvement in sleep latency and duration




Insulin Sliding Scale

Higher risk of hypoglycemia without improvement of hyperglycemia management regardless of care setting





Can cause extrapyramidal effects including tardive dyskinesia, risk may be greater in frail elderly

Avoid, unless for gastroparesis




Higher risk of delirium than other opioids, safer alternatives available





Increased risk of GI bleeding , acute kidney injury




From The American Geriatrics Society 2015 Beers Criteria Update Expert Panel, American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, J Am Geriatr Soc 63:2227–2246, 2015

Table 9.2
Frailty tools and associated outcomes

Frailty measure


Clinical outcome

Frailty phenotype

Weight loss, grip strength, exhaustion, low physical activity and 15 feet walking speeda

30-day complications, institutionalization, length of stay

Frailty Index/deficit accumulation

30–70 measures of comorbidity , ADL, physical and neurological exam

Mortality and institutionalization

Modified frailty index

History of diabetes; COPD, or pneumonia; congestive heart failure; myocardial infarction; angina/PCI; hypertension requiring medication; peripheral vascular disease; dementia; TIA or CVA; CVA with neurological deficit; ADL

30 days, 1-year, and 2-year mortality, 30 days major postoperative complications

Gait speed

5-m Gait >6 sa

Mortality, major postoperative complications, institutionalization, and length of stay

Timed up and go (TUG)

TUG <10s, 11–14 s, >15 sa

1-year mortality


Katz Score, Mini cognition, Charlson Index , anemia <35 %, albumin <3.4, hx of falls

30 days major postoperative complications, length of stay, 30 days readmission, 6 months postoperative mortality

Used with permission from Amrock LG, Deiner S., The implication of frailty on preoperative risk assessment. Curr Opin Anaesthesiol. 2014 Jun;27(3):330–5

aSee Chap. 8, Screening Tools for Geriatric Assessment by Specialists, for details on employing these measures

9.3 Frailty and Postsurgical Outcomes

Frailty is a syndrome which transcends comorbidity and is characterized by fatigue, weight loss, and low functional activity levels[9]. The frailty phenotype is associated with significant perioperative morbidity and mortality[10, 11]. Frailty is more common in older surgical patients when compared to community dwelling older people. Recent studies in both cardiac and noncardiac surgical populations suggest that preoperative frailty is a predictor of complications such as infection, reintubation, pneumonia, hospital length of stay, institutionalization, and mortality (Table 9.3) [6, 1215]. Frailty may be amenable to treatment with nutritional support, prehabilitation, rehabilitation, and vitamin supplementation [16, 17]. Therefore, preoperative identification of frailty is useful for risk stratification, discharge planning and may identify patients whose condition could be optimized prior to surgery [18].

Table 9.3
Summary of recommendations from the AGS expert panel on postoperative delirium clinical practice guideline

Strong Recommendations: (The evidence for each intervention where either the benefits clearly outweighed the risks or that the risks clearly outweighed the benefits.)

• Multicomponent nonpharmacologic interventions delivered by an interdisciplinary team should be administered to at-risk older adults to prevent delirium.

• Ongoing educational programs regarding delirium should be provided for healthcare professionals.

• A medical evaluation should be performed to identify and manage underlying contributors to delirium.

• Pain management (preferably with non-opioid medications) should be optimized to prevent postoperative delirium.

• Medications with high risk for precipitating delirium should be avoided.

• Cholinesterase inhibitors should not be newly prescribed to prevent or treat postoperative delirium.

• Benzodiazepines should not be used as first-line treatment of agitation associated with delirium.

• Antipsychotics and benzodiazepines should be avoided for treatment of hypoactive delirium.

Weak Recommendations: (The evidence favors these interventions, but the current level of evidence or potential risks did not support a strong recommendation.)

• Multicomponent nonpharmacologic interventions implemented by an interdisciplinary team may be considered when an older adult is diagnosed with postoperative delirium to improve clinical outcomes.

• The use of regional anesthetic at the time of surgery and postoperatively to improve pain control with the goal of preventing delirium may be considered.

• The use of antipsychotics (e.g., haloperidol, risperidone, olanzapine, quetiapine, or ziprasidone) at the lowest effective dose for the shortest possible duration may be considered to treat delirious patients who are severely agitated or distressed or who are threatening substantial harm to self and/or others.

Statements with Insufficient evidence: (The current level of evidence or potential risks of the treatment did not support either a strong or weak recommendation.)

• Use of processed electroencephalographic (EEG) monitors of anesthetic depth during intravenous sedation or general anesthesia may be used to prevent delirium.

• Prophylactic use of antipsychotic medications to prevent delirium

From The American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults, American Geriatrics Society Abstracted Clinical Practice Guideline for Postoperative Delirium in Older Adults, J Am Geriatr Soc 63:142–150, 2015

Traditional frailty assessments are time consuming and require trained personnel [19] although short form screening tools have been developed and can be administered by a layperson making them more relevant to the preoperative evaluation when attempting to identify older frail patients [20]. While frailty screening is currently not the universal standard of care, such a holistic approach will likely become useful to identify patients at risk for adverse outcomes and allow not only for risk stratification, but to aid in patient and family counseling, and identify interventions to reduce postoperative complications. The reader is referred to Chap. 1 on Frailty for a full discussion.

9.4 Perioperative Assessment and Management of Medications

Geriatric surgical patients are at high risk for polypharmacy and medication errors. This is compounded by frequent discrepancies between the surgical and anesthesiology medication records [21]. Polypharmacy is a strong predictor of such discrepancies [22]. Strategies to reduce discrepancies include encouraging patients to carry an updated medication list provided by their physician [22, 23] and medication reconciliation conducted by a clinical pharmacist at both hospital admission and discharge. Most chronic medications can be continued throughout the perioperative period while others may complicate intraoperative anesthetic management and affect postoperative outcomes. In this section we discuss the perioperative management of medications commonly used by older people.

Antihypertensive medications are commonly prescribed for older patients for blood pressure control. In most circumstances antihypertensive medications should be continued in the perioperative period, however, some antihypertensive medications require special consideration. Perioperative use of angiotensin converting enzyme (ACE) inhibitors /angiotensin receptor blockers (ARB) have been associated with protracted perioperative hypotension due to suppression of the renin-angiotensin-aldosterone-system (RAAS) preventing the normal hormonal and sympathetic response to surgical stress. However, the traditional practice of withholding ACE inhibitors and ARBs prior to elective surgery has recently been challenged because ACE/ARB related intraoperative hypotension has not been linked to adverse perioperative outcomes [24]. The 2014 ACC/AHA guidelines state that continuation of ACE inhibitors and ARBs is reasonable, and that if they are discontinued they should be restarted as soon as medically feasible [25, 26]. Generally, it seems reasonable to withhold ACE/ARB based on the patient’s presenting blood pressure, likelihood of intraoperative fluid shifts, and risk of hypotension in the light of either surgical or medical conditions. Beta blockers are another commonly prescribed class of antihypertensive drugs that were thought to decrease risk of perioperative cardiac events. However, the PeriOperative ISchemic Evaluation (POISE) trial demonstrated that the benefit of beta blockers on the incidence of perioperative cardiac events was off-set by an increased incidence of perioperative stroke [27]. Current ACC/AHA guidelines recommend continuing beta blockers in the perioperative period for patients who take them chronically (Class 1 evidence) [25].

9.5 Antiplatelet Agents

Chronic use of antiplatelet drugs is common in older surgical patients to prevent thrombosis in patients with known history of atrial fibrillation, coronary artery disease, cardiac stents, or stroke. Prevention of thrombosis may be even more important in the perioperative period, which is characterized by a proinflammatory state which increases platelet activity and aggregation. However, the benefits of antiplatelet drugs must be balanced by the risk of intra and postoperative hemorrhage.

9.5.1 Aspirin

Aspirin is an irreversible cyclooxygenase-1 (COX-1) inhibitor which disables platelet aggregation. Aspirin has become ubiquitous in the treatment, primary and secondary prevention of myocardial infarction and stroke [28]. The benefits of aspirin for secondary prevention of cardiovascular disease are well established and according to ACC/AHA guidelines should be continued indefinitely in most patients with established coronary artery and other atherosclerotic disease. However, the risk-versus-benefit ratio for primary prevention is less clear. A meta-analysis of six primary prevention trials found that there was no reduction in vascular-related mortality attributed to aspirin use and that the rates of gastrointestinal bleeding and hemorrhagic stroke were increased [29]. Furthermore, administration of aspirin in the perioperative period has not been shown to affect perioperative death or nonfatal myocardial infarction but does increase the risk of major bleeding [30]. Whether to continue aspirin in patients who are at high risk of perioperative thrombosis should be discussed with the patient, surgeon, and cardiologist prior to surgery.

9.5.2 Thienopyridines

Thienopyridines prevent platelet aggregation by inhibiting the P2Y12 receptor on platelet membranes and preventing adenosine diphosphate binding. Clopidogrel is the most commonly used antiplatelet medication in this class. These medications are used for primary and secondary prevention thromboembolic events in patients with cardiovascular and cerebrovascular disease and have gained widespread use as a component of dual antiplatelet therapy with aspirin in patients with cardiac stents to prevent thrombosis. Most centers discourage elective surgery in the immediate period following cardiac stent placement when it would require early cessation of clopidogrel due to risk of stent thrombosis and mortality. However, the definition of early discontinuation is evolving and many new generation stents require only 6 months of therapy [31]. Appropriate timing of antiplatelet therapy discontinuation after stent placement should be discussed with the cardiologist, surgeon, and patient. In particular it is important to discuss the balance between the location and type of stent, the time since the stent was placed, and the urgency of the surgical procedure.

9.6 Antidepressants

Depression affects 15–20 % of elders and is the most common psychiatric disorder in older people. Many older patients are prescribed antidepressant medications and consequences of their use in the perioperative period should be considered preoperatively [32]. Older generation antidepressants such as monoamine oxidase inhibitors (MAO-I) may interact with medications (e.g., meperidine and ephedrine) administered in the perioperative period leading to increasing anesthetic requirements, hypertensive crises, and potentially to life threatening hyperthermia and coma. It is unclear how long or whether patients should discontinue use of MAOIs prior to surgery. Although traditional recommendations have been to discontinue these agents for 2 weeks to 30 days before surgery, many of these recommendations were not based on high quality studies. There is some concern that doing so may result in significant morbidity or even mortality in patients who depend on these medications for the management of their depression. The newer generations of antidepressants such as serotonin reuptake inhibitors (SSRIs) tend to have fewer side effects and are generally continued throughout the perioperative period. However SSRIs are associated with platelet dysfunction and bleeding [33, 34] and this risk should be balanced with the risk of postoperative depression [35]. Accordingly, it is important to identify older patients taking antidepressants prior to surgery so that a treatment plan can be developed between the patient and primary care provider or psychiatrist.

9.7 Analgesics

9.7.1 Non-Opioid Analgesics

Many older people depend on NSAIDs and COX inhibitors for daily relief of mild to moderate chronic pain. However, NSAIDs have significant systemic side effects and are associated with up to a quarter of all adverse drug reactions in the older people [36]. Side effects of NSAIDS and COX inhibitors include: increases in mean arterial pressure, renal vasoconstriction, and sodium reabsorption leading to fluid retention and edema. Most surgeons advocate for cessation of NSAIDs 7–10 days prior to surgery due to concerns of perioperative hemorrhage; other studies suggest that the effects of NSAIDS and COX wane quickly and may be clinically irrelevant [37]. For patients that depend on NSAIDs, their continuation should be discussed with the surgeon to balance the risk of bleeding and with the need for pain control.

Non-opioid analgesics (e.g., acetaminophen and gabapentin) can usually be continued through the perioperative period and have been shown to decrease opioid requirements, improve functional outcome, and increase patient satisfaction postoperatively [38, 39]. Note that the dose of gabapentin and pregabalin is limited by side effects [40, 41]. Overall, multimodal analgesia may be beneficial but there is little data regarding the best regimen in elders [42].

9.7.2 Opioid Analgesics

Approximately 15–20 % of the community dwelling geriatric population and over 40 % of those living in nursing homes experience chronic pain that may require management with opioid medications [43]. Appropriate opioid dosing is complicated by age-related changes in total body water, lean muscle mass, and increased in body fat. These changes may lead to unpredictable drug responses due to changes in the volume of distribution, plasma concentration, and elimination profiles. Physiologic and pathophysiologic changes in renal function, hepatic metabolism, and central nervous system sensitivity may increase drug effects, duration of action, and incidence of side effects [44].

In most circumstances, opioid medications should be continued in the perioperative period. Withholding chronic pain medications results in patient discomfort and may cause symptoms of withdrawal. Chronic opioid use results in habituation which does not meet criteria for addiction. Opioid addiction occurs in older people, although at a lower rate compared to younger patients. The prevalence of drug abuse by Americans aged ≥65 years is tenfold lower than that of younger patients [45].

An important part of the preoperative assessment involves a plan for intraoperative and postoperative opioid administration. For example, calculating daily morphine equivalents based on home medications may be helpful in estimating baseline need. While baseline opioid dose may not be adequate in the perioperative period, calculation of daily opioid equivalents provides a starting point for therapy [46].

9.8 Intraoperative Anesthetic Management of an Older Patient

9.8.1 Physiology of Aging Organ Systems and Their Impact on Anesthetic Management

Cardiac changes that occur with advanced age include increased afterload due to arterial stiffening, elevated systolic blood pressure, left ventricular hypertrophy (LVH), valvular disease, and coronary artery disease. Notably, baroreceptor function is depressed, whereas cardiac output appears to be maintained in healthy individuals. LVH of normal aging causes some level of diastolic dysfunction which may only be symptomatic under stress as occurs with aggressive fluid therapy which may be necessary to support blood pressure during anesthesia. Increased vagal tone and decreased sensitivity of adrenergic receptors lead to a decline in heart rate by approximately one beat per minute per year of age after age 50 [47]. Fibrosis of the conduction system and loss of sinoatrial node cells increase the incidence of dysrhythmias, particularly atrial fibrillation and flutter. This physiology predisposes the older patient to exaggerated drops in blood pressure under anesthesia.

In the pulmonary system , decreased elasticity of lung tissue results in shallower alveoli and reduced size of small airway that in turn results in decreased alveolar surface area and an increase in the alveolar-arterial gradient with age and calculated by the following formula, Pao2 = 110 − (0.4 × age). Respiratory mechanics are also altered in normal aging due to calcification of the costo-chondral margins and sarcopenia of the intercostal and diaphragmatic muscles. These changes increase closing volume so that it exceeds functional residual capacity by 45 years of age in the supine position and age 65 in the sitting position [48]. When this happens, some airways are closed during all or part of normal tidal breathing, resulting in a mismatch of ventilation and perfusion. Both anatomic and physiological dead space increase contribute to a higher risk of hypoxia with even mild hypoventilation or brief apnea. In the immediate postoperative period, protective laryngeal reflexes may be subdued and this may lead to a higher risk of pulmonary aspiration.

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Aug 25, 2017 | Posted by in GERIATRICS | Comments Off on Anesthesia for the Older Patient

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