What the Anesthesiologist Should Know before the Operative Procedure
Increased life expectancy, safer anesthesia, and less invasive surgical procedures have made it possible for a greater number of geriatric patients to be considered for surgery. Ageing is associated with a progressive loss of functional reserve in all organ systems. The extent and onset of these changes vary from individual to individual. Anticipating the interaction between underlying disease, limited end-organ reserve and the stress of the perioperative period aids in providing the best possible care.
Age itself adds very little additional risk in the absence of comorbid disease. However, elderly patients have some unique risks. Older patients are more prone to postoperative delirium, aspiration, urosepsis, adverse drug reactions, pressure ulcers, malnutrition, falls, and failure to return to ambulation or home.
In elderly patients, as in any other age group, quality of life is of paramount importance. The goal of surgery should be to relieve suffering and maintain independence and dignity.
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1. What is the urgency of the surgery?
What is the risk of delay in order to obtain additional preoperative information?
Emergency surgery is an independent predictor of adverse postoperative outcomes in geriatric patients undergoing non-cardiac surgery. Poorer preoperative physiology, frailty and poor functional status and preparation have a large influence on these results. The risk of delaying surgery must be weighed against the benefits of obtaining additional preoperative information or possible preoperative optimization.
Urgent/emergent
Emergency surgery in the elderly carries disproportionately high risk as patients tend to present later, are often harder to diagnose, and have poorer functional reserve. Much of the emergency surgery performed on elderly patients is for injuries due to trauma (e.g., femoral neck fracture). A minimally invasive technique may be performed (e.g., percutaneous drainage of a gallbladder empyema before planned cholecystectomy) to stabilize elderly people, thereby affording the opportunity for resuscitation and optimization before definitive surgery. Decision making for emergency surgery in elderly patients is often difficult due to incomplete information about comorbidities and needs to help patients and families make major decisions in a timely manner. Investigation, optimization, and discussion can all add delays to emergency surgery in elderly patients but are warranted, given the higher overall perioperative mortalities that occur in emergency surgeries [ie: hip fractures].
Elective
Major elective cardiac, vascular, oncological, and orthopedic surgery can be successfully performed on elderly patients with adverse event rates similar to younger patients.
2. Preoperative evaluation
A high index of suspicion for disease processes commonly associated with aging is needed. Routine medical clearance is a common cause of delay and may not be necessary. Assessment should be made of the degree of functional reserve of specific, pertinent organ systems and the patient as a whole.
Routine testing on the basis of age alone may not be indicated, especially for low-risk procedures. Lab testing should be guided by the patient’s history, physical examination, and anticipated surgical procedure.
Hearing and visual losses are common in the elderly. In performing a preoperative evaluation of the elderly patient, it is often helpful to sit directly in front of the patient so that he or she can see your lips and you should speak slowly and deliberately.
Medically unstable conditions warranting further evaluation include active ischemia and myocardial infarction (MI), unstable arrhythmias, congestive heart failure (CHF), stroke, transient ischemic attack (TIA), or chronic obstructive pulmonary disease (COPD) exacerbation. They warrant further assessment, consultation, and stabilization.
Delaying surgery may be indicated if there are unstable medical conditions.
3. What are the implications of co-existing disease on perioperative care?
Basal functioning of the body’s organ systems is relatively uncompromised by the aging process. However, functional reserve, and specifically the ability to compensate for physiological stress, is greatly reduced. This has important implications for the perioperative care of geriatric patients. Recognizing acute illness and exacerbations of chronic disease can be challenging as these changes may have an atypical presentation. For example, pneumonia in an elderly patient may present with the nonspecific features of confusion, lethargy, and general deterioration of condition.
b. Cardiovascular system
Age-related changes
Age-related changes of the cardiovascular system involve alterations in both cardiovascular mechanics and control mechanisms. A reduction in arterial elasticity results in elevated systolic blood pressure, increased afterload, and left ventricular hypertrophy. In the absence of coexisting disease, diastolic blood pressure remains relatively unchanged. Cardiac output appears to be maintained in healthy elderly patients but declines with age due to the effects of coexisting disease.
Some degree of diastolic dysfunction is associated with aging, although the extent of dysfunction is usually associated with the degree of hypertension, CAD, cardiomyopathy, and valvular heart disease. Baroreceptor function is depressed in the elderly. An increase in vagal tone and decreased sensitivity of adrenergic receptors result in a decline in heart rate. Fibrosis of the conduction system and loss of sinoatrial nodal cells increase the incidence of arrhythmias, especially atrial fibrillation.
Perioperative evaluation/risk reduction strategies
The American College of Cardiology (ACC)/American Heart Association (AHA) task force guidelines for preoperative evaluation recommend evaluating clinical history, surgical risk, and exercise tolerance to identify patients at increased cardiac risk during the perioperative period. Based on this evaluation, determination of whether additional cardiac evaluation is warranted can be made. Assessment of daily physical activities and exercise tolerance are the most valuable source of information in determining cardiac risk. In patients with limited exercise tolerance, chemical cardiac stress tests are often used to differentiate cardiac from non-cardiac causes. Stress echocardiography or cardiac catheterization may also be indicated to more precisely specify and quantify the degree of cardiac compromise. In many scenarios, perioperative care teams decide against further cardiac evaluation or intervention because evidence for its benefit is limited.
For a patient with a coronary artery stents, it is essential to ascertain when the stents were placed, their location, and what type (bare metal versus drug eluting) were placed. The patient’s cardiologist should be able to provide this information along with any recent studies evaluating patency or residual myocardium at risk. Patients may have a card given to them at the time of stent placement providing information on type and locations of the stents. Patients with drug eluting stents placed less than 1 year ago or bare metal stents implanted less than 6 weeks age are generally not candidates for elective surgery due to risk of thrombosis from discontinuation of antiplatelet agents in the perioperative period. If surgery is needed in a patient with recent stent placement, then a collaborative discussion should take place with the patient’s cardiologist, surgeon, and patient regarding risks/benefits of delaying surgery and management of antiplatelet agents in the perioperative period.
Preoperative hypertension should best be controlled preoperatively, although these is limited evidence available to suggest postponing elective surgery.
c. Pulmonary
Age-related changes
Gradual tissue degeneration resulting from loss of tissue elasticity occurs with aging. Loss of lung tissue elasticity compromises small airway patency and closing capacity increases. Chronic airway obstruction is common in the elderly. Changes in elasticity are non-uniform resulting in disruption of the normal matching of ventilation and perfusion of the lungs increasing both shunting and dead space. In addition, protective cough and swallow reflexes diminish with increasing age, resulting in micro-aspiration with resulting chronic pulmonary inflammation. Chronic exposure to noxious agents from smoking or other environmental or industrial chemicals may also contribute to worsening respiratory function.
Increased work of breathing resulting from reduced chest wall elasticity, increased turbulent airflow in narrowing airway passages, together with weakening of respiratory muscles place the elderly patient at increased risk of postoperative respiratory failure. Ventilatory responses to hypoxemia or hypercarbia are also decreased in the elderly. Common coexisting pulmonary diseases in the elderly include COPD, pneumonia, and sleep apnea.
Perioperative evaluation/risk reduction strategies
The presence of dyspnea, smoking, coughing, and wheezing can be assessed from the history. Valuable information regarding pulmonary function can be obtained by questioning the elderly patient with regard to ability to climb stairs provided that other causes for stopping (e.g., claudication, degenerative osteoarthritis) can be excluded.
Patients with COPD should receive preventive therapy with mucolytic and bronchodilating agents. Pulmonary infection should be well controlled before surgery. Chest physical therapy may decrease postoperative pulmonary complications.
d. Renal-GI:
Renal-hepatic:
Age-related changes
Renal atrophy results in a 50% reduction in the number of functioning nephrons by age 80 with a 1%-1.5% decline per year in glomerular filtration rate (GFR) compared to young adults. Creatinine clearance also declines with age. Serum creatinine level remains within normal limits due to a reduction in skeletal muscle mass and less creatinine production. Serum creatinine is a poor predictor of renal function in elderly patients. This is important for proper dosage adjustment for perioperative medications that are excreted by the kidneys. Alterations in electrolyte handling and the ability to dilute and concentrate urine also result from functional changes in the kidneys associated with aging. Renal capacity to conserve sodium is decreased and older patients have a tendency to lose sodium in the setting of inadequate salt intake. In addition a decreased thirst response in the elderly may place the geriatric patient at risk for dehydration and sodium depletion.
Liver mass decreases approximately 20%-40% with aging and hepatic blood flow decreases about 10% per decade. There is a variable decrease in the liver’s capacity to metabolize drugs especially phase 1 reactions. Decreases in hepatic blood flow may decrease the maintenance dose of drugs that are rapidly metabolized. The metabolism of drugs that are slowly metabolized are more affected by innate liver capacity than blood flow. Cirrhosis worsens these physiologic changes.
The elderly patient has more adipose tissue, decreased muscle mass, and less total body water than a younger patient, resulting in an increase in plasma concentration of water-soluble drugs. In contrast, increased adipose tissue might decrease the plasma concentration of lipid-soluble drugs. The glomerular filtration rate decreases with aging, resulting in decreased renal excretion of drugs and drug metabolites. Serum albumin, which is important for drug binding and hepatic blood flow (important for drug metabolism), also decreases with aging.
e. Neurologic:
Age-related changes
Nervous system function tends to decline with age, leading to impairments in cognition, motor, sensory, and autonomic function. However, there is great inter-individual variability in the degree to which these changes manifest in the elderly.
There is a reduction in brain mass with increasing age. This change is secondary to alteration in neuronal morphology with decrease in neuronal size and loss of complexity of dendritic tree and number of synapses. The synthesis of some neurotransmitters and the number of their receptors are also reduced. The autonomic nervous system function also declines with decrease in parasympathetic outflow and increased sympathetic autonomic activity. Changes in autonomic responses result in compromised thermoregulation, decreased baroreceptor responsiveness, and dehydration.
Many central nervous system diseases are more prevalent in the elderly including cerebral atherosclerosis, Parkinson’s disease, Alzheimer’s disease, dementia, and depression. Geriatric patients undergoing surgery are at risk for delirium. Postoperative delirium is associated with an increased risk for mortality.
Perioperative evaluation/risk reduction strategies
The Mini-Mental State Exam allows for quick screening of baseline cognitive status. In addition, information may be obtained by speaking with the patient’s family concerning baseline function and activities of daily living. Structured clinical protocols focused on risk factor modification for delirium management should be used. Pharmacologic prevention in general has not been successful for prevention of delirium, although dexmedetomidine may reduce delirium severity and duration in some patients by decreasing need for sedation and improving pain control. Clinical tools such as the Mini-Cog Exam may help identify preoperatively patients who may be at risk for delirium after elective surgery.
f. Endocrine:
Like other organs, endocrine glands atrophy with increasing age. Hormones including insulin, thyroxine, growth hormone, aldosterone, and testosterone may be deficient with disruption in hormonal homeostasis. Diabetes, hypothyroidism, osteoporosis, impotence, and electrolyte abnormalities are common in the elderly.
Diabetes is an important comorbidity to assess for in determining perioperative risk. The severity of end organ disease associated with diabetes is associated with increased cardiovascular morbidity and is a predictor of decreased quality of life following surgery. A thorough knowledge of the patient’s diabetic history is important including baseline glycemic control (HbA1c or daily fingerstick measurements) and the presence of long-term complications from diabetes including nephropathy, neuropathy, or cardiac disease. If persistently elevated glucose values are found, it may be beneficial to delay elective surgery until better glycemic control can be obtained. Infectious complications are more prevalent in diabetics with poor glycemic control.
g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
Gastrointestinal disease
Gastrointestinal (GI) disorders with higher incidence in the elderly include peptic ulcer disease, ischemic bowel, malignancies, and passive reflux. There is a higher risk of GI side effects from medications like nonsteroidal anti-inflammatory drugs (NSAIDs). Increased risk of constipation and bowel obstruction occurs with opioids in the elderly.
Musculoskeletal disease
There is an increased incidence of osteoarthritis with age. Rheumatoid arthritis is also prevalent in the elderly. These problems are associated with neck mobility and airway management. Radiographs of the cervical spine, flexion, and extension may be instrumental in deciding the safest approach to airway management without causing neck injury or compromising the spinal cord. Intervertebral disc degeneration of the spinal column with disc herniation and osteophyte formation is progressive in the elderly. This may lead to nerve root impingement and symptoms of spinal stenosis. Neuraxial blockade may be more difficult in the elderly. Osteoporosis and tendency to fall increase the incidence of hip fractures, which is the most common cause of traumatic injury in the elderly. Other musculoskeletal conditions prevalent in the elderly include gout, pseudogout, and polymyalgia rheumatica.
Functional assessment
Preoperative functional evaluation requires special attention in the geriatric patient. The evaluation of the geriatric patient in the “resting” state does not indicate how the patient will respond to the cardiac, pulmonary, and metabolic demands of the perioperative period. In addition to functional assessment of cardiopulmonary capacity, assessment of activities of daily living (ADLs), cognitive and emotional status, and urologic function may be beneficial. Measures of frailty, which reflect physiologic reserve and susceptibility to adverse outcomes, have been used to predict postoperative complications, length of stay and need for discharge to a skilled versus assisted nursing facility in elderly patients undergoing surgery.
Preoperative functional assessment is important because the goal is to return the patient to his/her preoperative activity level. The success of surgery must be questioned if the procedure is technically adequate but the patient suffers loss of independence. The older patient is at far greater risk for long-term functional compromise following the stress of surgery.
Nutritional assessment
The geriatric population is especially at risk for nutritional deficiencies. Appetite and calorie consumption decrease in the elderly patient and these changes may be further compounded by issues such as depression, isolation, alcohol consumption, and poor dentition. Malnourished patients have higher mortality, more falls, longer hospital stays, and more postoperative complications (e.g., infections and pressure sores).
Perioperative evaluation/risk reduction strategies
Initial assessment with body mass index (BMI) can be useful. A BMI < 18.5 kg/m2 may be indicative of low weight and possible malnutrition. Serum markers of albumin or pre-albumin may also be helpful. When deficiencies are identified on preoperative testing it is important to review causative factors. Determination of the deficit and its etiology gives the treating time to address the issue before the patient goes to surgery. In cases of severe malnutrition, elective surgeries can be postponed and enteral nutrition can be provided.
Consent, advanced directives and surrogate decision makers
All patients regardless of age should have advanced directives. The elderly patient anticipating surgery is in special need of attention to advance directive or assignment of a health care surrogate. Cognitive and sensory deficits may jeopardize providing informed consent in frail elderly patients. Clarification of “do not resuscitate” orders is a common problem that should be addressed preoperatively.
Assess the Patient for Frailty
Frailty as a component (or feature) of the pre-operative evaluation has become a standard in most medical and surgical communities.
A frailty phenotype was proposed in 2001 and characterized as a clinical syndrome in which three or more criteria were present: unintentional weight loss or 10 pounds in the past year; self-reported exhaustion; weakness in hand grip strength; slow walking speed and low physical activity. In 2013, The Frailty Consensus: A Call to Action made four recommendations: Frail individuals could be disabled, but not all disabled persons are frail; sarcopenia may be a component of frailty; well validated models of frailty exist such as the FRAIL Screening Questionnaire and physical frailty differs from multimorbidity. The Edmonton Frail Scale (EFS) is a fifteen point scale which is simple to administer and takes only five minutes. It has been used to assess the appropriateness of proceeding with chemotherapy in patients with colorectal cancer. Recently, frailty assessment schemes for specific surgeries such as the Modified Frailty Index for total hip arthroplasty have been created.
4. What are the patient's medications and how should they be managed in the perioperative period?
With the higher incidence of chronic disease in the elderly comes an increased use of prescription medication. The use of multiple medications (polypharmacy) increases the possibility of drug interactions and risk of adverse medication-related events. Elderly patients may also be using over-the counter medications, home remedies, and dietary supplements, which can have significant interactions with medications administered during the perioperative period. The elderly patient’s use of alcohol, sleeping aids, and pain medications should be specifically addressed as sudden withdrawal may contribute to development of postoperative delirium.
An accurate list of all medications should be made available to providers during the perioperative period. It is important to question the role of each drug that the patient is taking. It is not uncommon for a medication to be initiated for a specific indication but never stopped when the indication resolved. It is reasonable to eliminate any unnecessary drugs before the time of surgery.
It is important to communicate clearly with the patient and family member or caregiver to be sure that instructions regarding their medications prior to and after surgery are clearly understood. Providing written instructions in addition to verbal instruction may be additionally helpful.
h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
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i. What should be recommended with regard to continuation of medications taken chronically?
Cardiac medications
Beta blockers: Current data suggest that administration of beta blockers reduces cardiovascular events in certain patient groups undergoing surgery but may increase mortality and perioperative stroke rates.
Current AHA/ACC guidelines support administration of beta blockers in two groups of patients:
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Patients with known or multiple risk factors for ischemic heart disease undergoing vascular surgery. These patients should be prescribed beta blockers preoperatively if not already on them
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Patients who are already on beta blockers, particularly those with independent cardiac indications for these medications (e.g., history of arrhythmias or myocardial infarction [MI]).
For geriatric patients, beta blockers should be started if the patient has cardiac risk factors and extreme caution should be given to monitor for bradycardia and hypotension. If beta blockers are already being used they should be continued. Intravenous beta blockers can be used until the patient can resume their oral formulations.
Statins
Current data suggest that statin therapy may be beneficial in reducing perioperative rates of myocardial infarction, stroke, and death in high-risk individuals undergoing intermediate- or high-risk surgeries. Abrupt discontinuation of statins has been associated with increased risk of MI and death and thus continuation of statins in the perioperative period is recommended. Statins are not available in IV formulation but extended release formulations may be used to bridge the NPO (nothing by mouth) period of surgery.
Antihypertensive medications
Hypertension is prevalent in the geriatric population. Hypertension is associated with increased lability of blood pressure during the perioperative period. Every effort should be made to control hypertension preoperatively, and it is important to avoid abrupt discontinuation of antihypertensive medications during the perioperative period.
Pulmonary medications
Patients using inhalers (beta agonists, inhaled steroids, and anticholinergic medications) should continue these medications up to the time of surgery and resume them immediately postoperatively. Leukotriene inhibitors and lipooxygenase inhibitors do not appear to interact with anesthetics so these medications should also be continued during the perioperative period. Patients with severe asthma or COPD who have taken oral steroids for more than 2 weeks over the past year may require “stress dose” steroids.
Diabetes medications
Patients who use oral agents should discontinue their medications on the morning of surgery with short-acting insulin provided if perioperative hyperglycemia develops. Patients who manage their diabetes with insulin should typically administer one half to two thirds of their normal insulin dose on the morning of surgery. The exact dosing will depend on the timing of surgery (morning versus afternoon), type and duration of surgery, and baseline glucose control.
Neurologic medications
Geriatric patients often take one or more neurologic medication for dementia, depression, anxiety or Parkinson’s disease. Patients with Parkinson’s disease should be given their antiparkinson medications preoperatively and again postoperatively as soon as possible. Even a short break from carbidopa/levodopa can result in return of Parkinson’s symptoms. There are few intravenous formulations so resumption of oral intake is often necessary. Replacement can also occur via nasogastric (NG) tube if the tablets are dissolved in water.
Chronic pain medications
Chronic pain issues are common in the elderly and management can be especially difficult due to cognitive impairment and the overlap of pain-related behaviors and behaviors of dementia or depression. The patient and caregiver should be given specific instruction on which chronic pain medications to take on the morning of surgery. Consultation with the patient’s pain management physician or anticipating difficult cases and consulting pain medicine early in the perioperative course may be helpful.
Antiplatelet agents
Due to risk of bleeding, many surgeons are reluctant to continue aspirin in the perioperative period. However, the ACC/AHA guidelines clearly state that aspirin be continued throughout the perioperative period. Assessment of the risks of bleeding associated with the anticipated surgery is important. Other antiplatelet medications like clopidogrel and ticlopidine are routinely discontinued 7 days prior to surgery.
j. How To modify care for patients with known allergies
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k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
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l. Does the patient have any antibiotic allergies — Common antibiotic allergies and alternative antibiotics
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m. Does the patient have a history of allergy to anesthesia?
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5. What laboratory tests should be obtained and has everything been reviewed?
The purpose of ordering preoperative tests is to detect unsuspected abnormalities that might affect morbidity and mortality and then assess the severity of a condition that is already known. In addition, preoperative tests can be used to establish a baseline, especially when there is a concern that a particular condition might be adversely affected by the perioperative process. In general, the ordering of preoperative tests should be based on patient comorbidity and surgical risk.
Routine laboratory testing based on age alone may not be indicated for geriatric patients. In general the ordering of preoperative tests should be based on patient comorbidity and surgical risk.
The following is a list of the most commonly ordered tests and their place in the assessment of the geriatric patient undergoing surgery
Hemoglobin levels: For the geriatric patient undergoing preoperative evaluation, it is generally reasonable to assess a baseline hemoglobin value. A hemoglobin level of 9-10 g/dL is generally considered a minimum level need to proceed to surgery, although type of surgery, anticipated blood loss, and patient comorbidities also need to be taken into consideration. If anemia is present, then it is important to determine its etiology. Iron deficiency anemia may require work up with upper and lower endoscopy whereas vitamin B12 or folate deficiencies should be corrected with vitamin supplementation.
Electrolytes: An electrolyte panel is often ordered preoperatively for geriatric patients undergoing surgery. It is useful to assess the creatinine clearance which is helpful in determining dosages of postoperative medications. Furthermore a serum creatinine > 2.0 mg/dL is a predictor of postoperative cardiac complications in patients undergoing noncardiac surgery according to the revised cardiac risk index. In addition, the electrolyte panel provides levels of sodium, potassium and bicarbonate which may be abnormal because of dehydration, use of diuretics or angiotensin converting enzyme inhibitors.
Coagulation panel: Studies have shown a low incidence of discovering unsuspected disease with routine tests of coagulation (prothrombin time (PT)/partial thromboplastin time (PTT). The PT and PTT are only indicated in patients with known bleeding disorders or those with a history of bleeding. Patients with malnutrition, liver disease or malabsorption may have elevated PT values. In certain types of surgeries where even small amounts of bleeding can result in dramatic complications (e.g., spine, neurosurgical procedures) preoperative coagulation testing may be warranted
Urinalysis: The incidence of asymptomatic bacteruria increases with age although routine urinalysis should not be routinely ordered. If a patient reports signs or symptoms consistent with urinary tract infection, then it should be performed preoperatively.
Chest radiograph: Is recommended for geriatric patients with known cardiopulmonary disease and those with abnormalities of physical examination.
Electrocardiogram (ECGs): Indicated preoperatively in elderly patients with cardiac disease or with associated risk factors including hypertension, diabetes, elevated cholesterol, peripheral vascular disease or cerebral vascular disease. Since the prevalence of cardiovascular disease increases with age, it is often recommended that elderly patients have a preoperative ECG. The baseline ECG findings (e.g., prior MI, arrhythmias) can help identify patients with risk factors for perioperative complications.
Ambulatory versus inpatient surgery for the elderly patient
Ambulatory surgery has advantages for the elderly patient when possible because it allows the patient to return home to a familiar environment, thereby helping to reduce anxiety and disorientation. Decreased risk of hospital-acquired infections and earlier resumption of normal mobilization are additional advantages. Many commonly performed surgeries in elderly patients (e.g., cataracts, TURP, hernia repair) can be performed with minimally invasive surgery and minimally invasive anesthesia and are safely manageable in ambulatory settings.
Specific, evidence-based selection criteria for elderly outpatient surgery are lacking. Since the elderly have high inter-individual variability, they are difficult to characterize as a single group. As a general principle, elderly patients with uncompensated or poorly stabilized conditions are at high risk of perioperative complications and should be managed with inpatient surgery.
Availability of caregivers can be lacking if the patient is older and will preclude ambulatory surgery. Patient comprehension, which is an important selection criterion, for ambulatory surgery may be reduced due to sensory deficits or cognitive impairment.
Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
The options for anesthetic management in the elderly include monitored anesthetic care (MAC), regional, and general anesthesia. The decision of which technique to use depends on the type of surgery to be performed as well as patient specific factors. General considerations for anesthetic management in the elderly include:
Positioning
Careful positioning is essential regardless of the anesthetic technique employed. Arthritis is almost universal in the elderly. Restriction of joint mobility may lead to difficulty in obtaining an optimal position for surgery or regional anesthesia. Excessive joint manipulation may result in severe pain postoperatively. Decreased skin elasticity and thinner layers of subcutaneous fat place elderly patients at increased risk for skin breakdown, pressure sores, and nerve injury. Additional vigilance in care of pressure areas is important to reduce the risk of these complications.
Monitoring/intravenous access
Decisions regarding invasive monitoring and intravenous access should be based on the underlying patient functional status and nature of the anticipated surgery. Elderly patients with comorbidities may need invasive monitoring for minor surgical procedures. Intravenous access may be rapidly lost because of thin fragile vessels. Adhesive tapes for securing an IV line may damage the fragile skin of an elderly patient and specialized dressings may be needed.
Sedation/premedication
Use of premedication in the elderly should be considered carefully. Elderly patients are more sensitive to sedative agents. Use of midazolam has been associated with delayed PACU discharge and increased incidence of postoperative arterial desaturation and may contribute to postoperative delirium.
Thermoregulation
Elderly are at greater risk for hypothermia due to alterations in central temperature regulation, altered shivering threshold, impaired vasoconstriction, and reduced metabolic activity. Perioperative hypothermia is associated with a number of perioperative adverse events including poor wound healing, susceptibility to infections, discomfort, and increased cardiovascular stress. Normothermia should be maintained by increasing the ambient OR temperature, the use of forced air warmers, humidity-moisture exchanges, and warming intravenous fluids.
Regional anesthesia
It is often suggested that regional anesthesia be employed in geriatric patients whenever possible due to depression of cardiovascular function associated with general anesthesia. In addition it is suggested that maintenance of consciousness during regional anesthesia permits early recognition of changes in cognitive function or the onset of cardiovascular symptoms such as angina. Most evidence suggests little, if any, difference in outcome between regional and general anesthesia in elderly patients. Use of regional anesthesia does not seem to decrease the incidence of postoperative cognitive dysfunction. Impairment of cognitive function precludes use of a regional technique in many cases. Performing regional blockade may be challenging because of difficulty in patient positioning, calcification of spinous ligaments. and vertebral collapse caused by osteoporosis. Larger gauge spinal needles may be used because the incidence of post-dural puncture headache is reduced in the elderly.
Neuraxial
Benefits: Does not require instrumentation of the airway, which allows patients to maintain their own airway and level of pulmonary function. Decreases in DVT after total hip arthroplasty, decreased incidence of postoperative graft thrombosis after lower extremity revascularization, and decreased blood loss in pelvic and lower extremity surgery have been reported in some studies.
Drawbacks: Age-related cardiovascular alterations, sympathetic blockade, and consequent decrease in peripheral vascular resistance may produce profound hypotension and bradycardia, especially in an elderly patient with reduced cardiovascular reserve. Increased risk of urinary retention and need for postoperative catheterization often occur in elderly patients after neuraxial anesthesia.
Issues: Decreased latency time, reduced CSF volume, and increased CSF density cause greater diffusion of local anesthetics. Demyelination of nerve fibers may also cause wider block extension. Consequently a reduction in local anesthetic dosage is recommended.
General anesthesia
Anesthetic agents
The elderly are more sensitive to anesthetic agents. Lower clinical doses are required to achieve a desired clinical effect and the pharmacologic effects are often prolonged. Undesired effects of anesthetics such as hemodynamic alterations occur in greater magnitude and expected compensatory or reflex responses may be blunted or absent. These differences in responses are the result of alterations in distribution and clearance of drugs (pharmacokinetics) as well as increased sensitivity to the target organs (pharmacodynamics) in the elderly patient. Dosage adjustments for the majority of medications administered during anesthesia are needed. Gradual titration to effect is preferred to large bolus administration. Intravenous medications may have a longer circulation time and delayed onset of effect.
A growing body of data suggests a possible association between anesthesia, surgical and long-term neurocognitive effects. However no study to date has shown that general anesthetics administered at clinically relevant doses for clinically relevant durations case neurotoxicity in humans. There is no scientific basis for either recommending or contraindicating specific anesthetic agents on the basis of neurotoxicity in the elderly.
Airway management
Limited neck movement caused by arthritic changes may present difficulties in securing the airway. The edentulous state in an elderly patient may make mask airway more difficult. Leaving dentures in place usually prevents this problem. Pre-oxygenation may be impaired because of increased closing capacity. Reduction in upper airway tone in the elderly increases the likelihood of obstruction during sleep (especially vigilant if sedation is administered). The decision between using an endotracheal tube and LMA depends on the balance between protecting the airway from aspiration (more common in the elderly) and the stress response and laryngeal trauma from intubation.
Hemodynamic management
Hemodynamic responses to intravenous and volatile anesthetic agents may be exaggerated by their effects on vascular preload, myocardial depression and sympatholysis. Protective baroreceptor reflexes may be ablated due to alterations in baroreceptor function or vagal tone. Careful assessment of intravascular volume is important as the elderly often present with hypovolemia due to impaired conservation of free water, decreased thirst and treatment with diuretics. Increased ventricular stiffness and diastolic dysfunction make the elderly patient more sensitive to both hypovolemia and fluid overload.
Monitored anesthesia care
Benefits: Sedation provided during local or regional anesthesia plays an important role in increasing comfort. Monitored anesthesia care (MAC) is an attractive option for the elderly and should be considered when possible. Ensuring elderly patients of comfort with sedation during procedures performed with local anesthesia improves satisfaction and compliance
Drawbacks: With reduced physiologic reserves, the elderly are more prone to develop circulatory and respiratory complications with sedation. Unintentional general anesthesia under propofol-based sedation is more common in elderly patients. Delirium can occur even with sedation.
6. What is the author's preferred method of anesthesia technique and why?
Prompt and complete recovery of baseline mental function is particularly important in the elderly surgical patient. Some data suggest that prolonged deep levels of anesthesia may increase mortality in elderly surgical patients. Consequently titration of anesthetic depth to the minimum value needed to avoid awareness should be encouraged. The use of short acting anesthetics and muscle relaxants which are minimally dependent on end organ clearance may be especially useful.
Emergence from anesthesia is a complicated endpoint in the elderly patient, influenced by normal age-related physiological changes as well as pathophysiologic alterations associated with coexisting disease. Even well planned anesthetics may result in delayed emergence in the elderly. When delayed emergence occurs it is important to think systematically about the pharmacologic, metabolic and neurologic factors which may be contributing.
a. Neurologic:
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b. If the patient is intubated, are there any special criteria for extubation?
As in a younger patient, the criteria for the extubation of the elderly include adequate gas exchange, adequate respiratory drive and strength, ability to cough and manage secretions, presence of adequate airway protective reflexes and appropriate level of consciousness. It is important to keep in mind that aging is associated with a decrease in the usual protective airway reflexes which places the patient at increased risk of aspiration. Patients with swallowing disorders, Parkinson’s disease and other neurologic disorders more prevalent in the elderly are at increased risk of aspiration. Assuring return to baseline level of consciousness before extubation is especially important.
c. Postoperative management
How to manage postoperative pain in the elderly patient
Pain perception does not decrease with age. Pain in elderly surgical patients remains undermanaged. Inadequate pain control has been linked to a number of adverse outcomes in the elderly patient including increased delirium, decreased ambulation, increased pulmonary complications, longer hospitalization and decreased postoperative functional status. Cognitive impairment may make pain assessment difficult or interfere with reporting pain.
Simple and consistent pain scales should be used for assessment. Preoperative education about pain management decreases postoperative pain. Postoperative pain management should include concurrent treatment of pre-existing chronic pain. Multimodal analgesia, using acetaminophen, NSAIDs or other non-opioid drugs is the best way to decrease opioid consumption and opioid related adverse events. Opioids should be administered at 25-50% of the adult dose and titrated until pain is reduced to a mild level. Elderly patients should be monitored closely to prevent side effects from opioid accumulation.
What level of bed acuity is appropriate?
The choice of floor, telemetry, step down unit, or ICU (intensive care unit) admission depends on the patient’s preoperative comorbidities, intraoperative course, and hospital resources. Age alone should not dictate level of bed acuity needed postoperatively.
What are common postoperative complications and ways to prevent them?
Neurologic
Delirium: Postoperative delirium is the most common neurologic complication in the geriatric subpopulation of surgical patients ranging in incidence from 15-50% depending on the procedure. Delirium is defined as a acute change in mental status with inattention and altered level of consciousness that tend to fluctuate during the course of a day. Perceptual disturbances, psychomotor or memory impairment and disorganized thought processes also occur. Risk factors include baseline cognitive impairment, sleep deprivation, immobility, visual or hearing impairment and dehydration. Multiple perioperative factors are associated with delirium including medications (especially narcotics, sedatives, anticholinergics), hypoxia, hypercarbia, pain, fever, blood loss, infections (UTI [urinary tract infection], pneumonia) and electrolyte disturbances.
Management: Structured clinical protocols focused on risk factor modification for delirium management should be used. Prophylactic low dose dexmedetomidine for delirium in high risk orthopedic patients should be considered. Correction of abnormal electrolyte values and glucose is important. Control of postoperative pain is important in preventing delirium. The patient’s medication profile should regularly be assessed for simplification to avoid polypharmacy and to eliminate drugs reported to precipitate delirium.
Postoperative cognitive dysfunction
Many elderly patients experience difficulties with memory, concentration, or attention after anesthesia and surgery. These changes are often short lived with normal function returning in a few days but may persist for weeks or more. The causes of postoperative cognitive dysfunction (POCD) are likely to be multifactorial including age, educational level, duration of anesthesia, postoperative infection and preoperative systems of depression or cognitive decline. Prevention and treatment of POCD is still undefined. Reassurance that the problem is genuine and likely transient may be helpful to patients.
Cardiac
Advances in preoperative risk assessment, surgical and anesthetic techniques, and implementation of medical therapy have reduced the frequency of cardiovascular complications associated with surgery. Despite these advances, cardiovascular complications represent one of the most common adverse consequences of non-cardiac surgery in the elderly. Those patients who have a symptomatic MI after surgery have a marked increase in the risk of death. Because of the increased risk of both short- and long-term mortality from a perioperative MI, accurate early diagnosis and management is essential.
Management: Close monitoring for myocardial ischemia is important. In elderly patients without documented CAD, surveillance should be restricted to those who develop perioperative signs of cardiovascular dysfunction. In patients with high or intermediate clinical risk who have known or suspected CAD and who are undergoing high- or intermediate-risk surgical procedures, obtaining ECGs at baseline, immediately after the surgical procedure and daily on the first 2 days after surgery is recommended. The use troponin measurements to supplement the diagnosis of MI of symptomatic patients is warranted.
Medications that decrease the frequency of cardiovascular complications should be continued, including beta-adrenergic blockers and statins. Antiplatelet agents should be continued throughout the perioperative period or restarted postoperatively as soon as is considered safe from a bleeding standpoint.
Pulmonary
Postoperative respiratory complications are common in the elderly and include pneumonia, hypoxemia, hypoventilation, and atelectasis. Predictors of adverse postoperative pulmonary complications include: smoking, underlying lung disease (COPD, asthma), duration of surgery, site of surgery (thoracic, upper abdominal), administration of general anesthesia, and multiple transfusions.
Management: Lung expansion modalities including chest physiotherapy, deep breathing exercises, incentive spirometry and continuous positive airway pressure (CPAP) should be implemented to increase postoperative functional residual capacity (FRC) and re-expand collapsed alveoli. Aspiration risk is increased in the elderly and requires careful monitoring. Assuring good postoperative pain control is important to decreasing postoperative pulmonary complications especially in patients undergoing upper abdominal or thoracic procedures.
Readmission: There is a higher risk of hospital readmission in elderly patients after surgery and readmission is associated with an increased risk of mortality. Presence of coexisting diseases, recent inpatient hospital admission and invasiveness of the procedure are other risk factors.
Functional decline: The goal of surgery in the elderly should be to return the patient to his/her baseline functional status and level of independence. However for many elderly patients (especially high risk patients undergoing major surgery) return to baseline function may be the exception rather than the rule. Discussing realistic expectations for recovery with elderly patients and their families early in their perioperative course may be helpful.
Increased morbidity and mortality: From 10% to 40 % of elderly patients undergoing surgery develop a postoperative complication that can lead to serious adverse events. Even seemingly mild complications may profoundly alter the geriatric patient’s postoperative course resulting in a cascade of complications that may result in death.
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