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Anesthesia for the Elderly Patient

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Surgical Management of Elderly Patients

Abstract

Older surgical patients represent a challenge for the anesthesiologist, because aging induces a progressive loss of functional reserve in all organs and systems. Symptomatic comorbidities, treatment with multiple medications, and a reduced functional reserve make these patients more susceptible to anesthetic agents, and appropriate drug choice and tritation are required to achieve the desired clinical effect. Scientific evidence is insufficient to recommend a most appropriate anesthetic approach, and both the functional status of the patient and the type of surgery must be carefully considered, when selecting anesthetic drugs and techniques. Anesthesia-related complications are rare, especially when all the perioperative period has been planned in detail by the full team taking care of the patient: physician, surgeon, and anesthesiologist. After surgery, older adults are at high risk of cognitive impairments, such as delirium and decline in cognitive functions, and great care must be taken to identify patients at high risk for cognitive impairments with the goal of returning the elderly to baseline conditions.

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References

  1. Grifasi C, Calogero A, Esposito A, Dodaro C. Perioperative care of elderly outpatients. A review. Ann Ital Chir. 2015;86(2):100–5.

    PubMed  Google Scholar 

  2. Alvis BD, Hughes CG. Physiology considerations in geriatric patients. Anesthesiol Clin. 2015;33(3):447–56.

    Article  Google Scholar 

  3. Brown EN, Purdon PL. The aging brain and anesthesia. Curr Opin Anaesthesiol. 2013;26(4):414–9.

    CAS  PubMed  Google Scholar 

  4. Tsui BC, Wagner A, Finucane B. Regional anaesthesia in the elderly: a clinical guide. Drugs Aging. 2004;21(14):895–910.

    Article  Google Scholar 

  5. Priebe HJ. The aged cardiovascular risk patient. Br J Anaesth. 2000;85(5):763–78.

    Article  CAS  Google Scholar 

  6. Scantlebury DC, Borlaug BA. Why are women more likely than men to develop heart failure with preserved ejection fraction? Curr Opin Cardiol. 2011;26(6):562–8.

    Article  Google Scholar 

  7. Sprung J, Gajic O, Warner DO. Review article: age related alterations in respiratory function - anesthetic considerations. Can J Anaesth. 2006;53(12):1244–57.

    Article  Google Scholar 

  8. Sorbini CA, Grassi V, Solinas E, Muiesan G. Arterial oxygen tension in relation to age in healthy subjects. Respiration. 1968;25(1):3–13.

    Article  CAS  Google Scholar 

  9. Schmucker DL. Age-related changes in liver structure and function: implications for disease ? Exp Gerontol. 2005;40(8–9):650–9.

    Article  CAS  Google Scholar 

  10. Martin JE, Sheaff MT. Renal ageing. J Pathol. 2007;211(2):198–205.

    Article  CAS  Google Scholar 

  11. Kruijt Spanjer MR, Bakker NA, Absalom AR. Pharmacology in the elderly and newer anaesthesia drugs. Best Pract Res Clin Anaesthesiol. 2011;25(3):355–65.

    Article  CAS  Google Scholar 

  12. Nickalls RWD, Mapleson WW. Age-related iso-MAC charts for isoflurane, sevoflurane and desflurane in man. Br J Anaesth. 2003;91(2):170–4.

    Article  CAS  Google Scholar 

  13. Van Cleve WC, Nair BG, Rooke GA. Associations between age and dosing of volatile Anesthetics in 2 academic hospitals. Anesth Analg. 2015;121(3):645–51.

    Article  Google Scholar 

  14. Monk TG, Saini V, Weldon BC, Sigl JC. Anesthetic management and one-year mortality after noncardiac surgery. Anesth Analg. 2005;100(2):4–10.

    Article  Google Scholar 

  15. Matsuura T, Oda Y, Tanaka K, Mori T, Nishikawa K, Asada A. Advance of age decreases the minimum alveolar concentrations of isoflurane and sevoflurane for maintaining bispectral index below 50. Br J Anaesth. 2009;102(3):331–5.

    Article  CAS  Google Scholar 

  16. Schnider TW, Minto CF, Shafer SL, Gambus PL, Andresen C, Goodale DB, et al. The influence of age on propofol pharmacodynamics. Anesthesiology. 1999;90(6):1502–16.

    Article  CAS  Google Scholar 

  17. Phillips AT, Deiner S, Lin HM, Andreopoulos E, Silverstein J, Levin MA. Propofol use in the elderly population: prevalence of overdose and association with 30-day mortality. Clin Ther. 2015;37(12):2676–85.

    Article  Google Scholar 

  18. Sun GC, Hsu MC, Chia YY, Chen PY, Shaw FZ. Effects of age and gender on intravenous midazolam premedication: a randomized double-blind study. Br J Anaesth. 2008;101(5):632–9.

    Article  CAS  Google Scholar 

  19. Wolff J, Bigler D, Christensen CB, Rasmussen SN, Andersen HB, Tønnesen KH. Influence of renal function on the elimination of morphine and morphine glucuronides. Eur J Clin Pharmacol. 1988;34(4):353–7.

    Article  CAS  Google Scholar 

  20. Shafer SL. The pharmacology of anesthetic drugs in elderly patients. Anesthesiol Clin North Am. 2000;18(1):1–29.

    Article  CAS  Google Scholar 

  21. Minto CF, Schnider TW, Egan TD, Youngs E, Lemmens HJ, Gambus PL, et al. Influence of age and gender on the pharmacokinetics and pharmacodynamics of remifentanil I. Model development. Anesthesiology. 1997;86(1):10–23.

    Article  CAS  Google Scholar 

  22. Minto CF, Schnider TW, Shafer SL. Pharmacokinetics and pharmacodynamics of remifentanil. II. Model application. Anesthesiology. 1997;86(1):24–33.

    Article  CAS  Google Scholar 

  23. Akhtar S, Liu J, Heng J, Dai F, Schonberger RB, Burg MM. Does intravenous induction dosing among patients undergoing gastrointestinal surgical procedures follow current recommendations: a study of contemporary practice. J Clin Anesth. 2016;33(9):208–15.

    Article  Google Scholar 

  24. Cope TM, Hunter JM. Selecting neuromuscular-blocking drugs for elderly patients. Drugs Aging. 2003;20(2):125–40.

    Article  CAS  Google Scholar 

  25. Berg H, Roed J, Viby-Mogensen J, Mortensen CR, Engbaek J, Skovgaard LT, et al. Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand. 1997;41(9):1095–103.

    Article  CAS  Google Scholar 

  26. Veering BT. Pharmacological aspects of local anesthetics in the elderly. Acta Anaesthesiol Belg. 1998;49(2):117–22.

    CAS  PubMed  Google Scholar 

  27. Simon MJG, Veering BT. Factors affecting the pharmacokinetics and neural block characteristics after epidural administration of local anaesthetics. Eur J Pain Suppl. 2010;4(S4):209–18.

    Article  CAS  Google Scholar 

  28. Racle JP, Benkhadra A, Poy JY, Gteizal B. Spinal analgesia with hyperbaric bupivacaine: influence of age. Br J Anaesth. 1988;60(5):508–14.

    Article  CAS  Google Scholar 

  29. Simon MJC, Veering BT, Stienstra R, van Kleef JW, Burm AGL. The effects of age on neural blockade and hemodynamic changes after epidural anesthesia with ropivacaine. Anesth Analg. 2002;94:1325–30.

    Article  CAS  Google Scholar 

  30. Paqueron X, Boccara G, Bendahou M, Coriat P, Riou B. Brachial plexus nerve block exhibits prolonged duration in the elderly. Anesthesiology. 2002;97(5):1245–9.

    Article  Google Scholar 

  31. Bettelli G. Preoperative evaluation in geriatric surgery: comorbidity, functional status and pharmacological history. Minerva Anestesiol. 2011;77(6):637–46.

    CAS  PubMed  Google Scholar 

  32. Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF, American College of Surgeons National Surgical Quality Improvement Program; American Geriatrics Society. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012;215(4):453–66.

    Article  Google Scholar 

  33. Mohanty S, Rosenthal RA, Russell MM, Neuman MD, Ko CY, Esnaola NF. Optimal perioperative management of the geriatric patient: a best practices guideline from the American College of Surgeons NSQIP and the American Geriatrics Society. Am Coll Surg. 2016;222(5):930–47.

    Article  Google Scholar 

  34. Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000;15(11):1021–7.

    Article  CAS  Google Scholar 

  35. Folstein MF, Folstein SE, McHugh PR. Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189–98.

    Article  CAS  Google Scholar 

  36. Lautrette A, Peigne V, Watts J, Souweine B, Azoulay E. Surrogate decision makers for incompetent ICU patients: a European perspective. Curr Opin Crit Care. 2008;14(6):714–9.

    Article  Google Scholar 

  37. Li C, Friedman B, Conwell Y, Fiscella K. Validity of the patient health questionnaire 2 (PHQ-2) in identifying major depression in older people. J Am Geriatr Soc. 2007;55(4):596–602.

    Article  Google Scholar 

  38. Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Audisio R, Borozdina A, Cherubini A, et al. European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium. Eur J Anaesthesiol. 2017;34(4):192–214.

    Article  Google Scholar 

  39. Nath B, Li Y, Carroll JE, Szabo G, Tseng JF, Shah SA. Alcohol exposure as a risk factor for adverse outcomes in elective surgery. J Gastrointest Surg. 2010;14(11):1732–41.

    Article  Google Scholar 

  40. Davenport DL, Ferraris VA, Hosokawa P, Henderson WG, Khuri SF, Mentzer RM Jr. Multivariable predictors of postoperative cardiac adverse events after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg. 2007;204(6):1199–210.

    Article  Google Scholar 

  41. Poldermans D, Bax JJ, Boersma E, De Hert S, Eeckhout E, Fowkes G, et al. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac Management in non-Cardiac Surgery: the task force for preoperative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). Eur J Anaesthesiol. 2010;27(2):92–137.

    Article  Google Scholar 

  42. Johnson RG, Arozullah AM, Neumayer L, Henderson WG, Hosokawa P, Khuri SF. Multivariable predictors of postoperative respiratory failure after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg. 2007;204(6):1188–98.

    Article  Google Scholar 

  43. Inouye SK, Peduzzi PN, Robison JT, Hughes JS, Horwitz RI, Concato J. Importance of functional measures in predicting mortality among older hospitalized patients. JAMA. 1998;279(15):1187–93.

    Article  CAS  Google Scholar 

  44. Mahoney FI, Barthel DW. Functional evaluation: the Barthel index. Md State Med J. 1965;14(2):61–5.

    CAS  PubMed  Google Scholar 

  45. Podsiadlo D, Richardson S. The timed ‘up & go’: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142–8.

    Article  CAS  Google Scholar 

  46. Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210(6):901–8.

    Article  Google Scholar 

  47. Guigoz Y, Lauque S, Vellas BJ. Identifying the elderly at risk for malnutrition. The mini nutritional assessment. Clin Geriatr Med. 2002;18(4):737–57.

    Article  Google Scholar 

  48. Jie B, Jiang ZM, Nolan MT, Zhu SN, Yu K, Kondrup J. Impact of preoperative nutritional support on clinical outcome in abdominal surgical patients at nutritional risk. Nutrition. 2012;28(10):1022–7.

    Article  Google Scholar 

  49. Carli F, Scheede-Bergdahl C. Prehabilitation to enhance perioperative care. Anesthesiol Clin. 2015;33(1):17–33.

    Article  Google Scholar 

  50. The American Geriatrics Society 2012 Beers Criteria Update Expert Panel 1. American Geriatrics Society updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616–31.

    Article  Google Scholar 

  51. Smith I, Kranke P, Murat I, Smith A, O'Sullivan G, Søreide E, et al. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2011;28(8):556–69.

    Article  Google Scholar 

  52. Hellström PM, Samuelsson B, Al-Ani AN, Hedström M. Normal gastric emptying time of a carbohydrate-rich drink in elderly patients with acute hip fracture: a pilot study. BMC Anesthesiol. 2017;17(1):23.

    Article  Google Scholar 

  53. Sessler DI, Sigl JC, Kelley SD, Chamoun NG, Manberg PJ, Saager L, et al. Hospital stay and mortality are increased in patients having a “triple low” of low blood pressure, low bispectral index, and low minimum alveolar concentration of volatile anesthesia. Anesthesiology. 2012;116(6):1195–203.

    Article  Google Scholar 

  54. Luger TJ, Kammerlander C, Luger MF, Kammerlander-Knauer U, Gosch M. Mode of anesthesia, mortality and outcome in geriatric patients. Z Gerontol Geriatr. 2014;47(2):110–24.

    Article  CAS  Google Scholar 

  55. GALA Trial Collaborative Group, Lewis SC, Warlow CP, Bodenham AR, Colam B, Rothwell PM, et al. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet. 2008;372(9656):2132–42.

    Article  Google Scholar 

  56. Luger TJ, Kammerlander C, Gosch M, Luger MF, Kammerlander-Knauer U, Roth T, et al. Neuroaxial versus general anaesthesia in geriatric patients for hip fracture surgery: does it matter? Osteoporos Int. 2010;21(Suppl 4):S555–72.

    Article  CAS  Google Scholar 

  57. Guay J, Choi P, Suresh S, Albert N, Kopp S, Pace NL. Neuraxial blockade for the prevention of postoperative mortality and major morbidity: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev. 2014;1:CD010108.

    Google Scholar 

  58. Bijker JB, van Klei WA, Vergouwe Y, Eleveld DJ, van Wolfswinkel L, Moons KGM, et al. Intraoperative hypotension and 1-year mortality after noncardiac surgery. Anesthesiology. 2009;111(6):1217–26.

    Article  Google Scholar 

  59. Neuman MD, Ellenberg SS, Magaziner JS, Feng R, Carson JL, the REGAIN Investigators. Regional versus general anesthesia for promoting independence after hip fracture (REGAIN): protocol for a pragmatic, international multicentre trial. BMJ Open. 2016;6(11):e013473.

    Article  Google Scholar 

  60. Holte K, Sharrock NE, Kehlet H. Pathophysiology and clinical implications of perioperative fluid excess. Br J Anaesth. 2002;89(4):622–32.

    Article  CAS  Google Scholar 

  61. Cecconi M, Fasano N, Langiano N, Divella M, Costa MG, Rhodes A, et al. Goal-directed haemodynamic therapy during elective total hip arthroplasty under regional anaesthesia. Crit Care. 2011;15(3):R132.

    Article  Google Scholar 

  62. Tommasino C. Management of postoperative nausea and vomiting. In: Brambrink AM, Kirsch JR, editors. Essential of neurosurgical anesthesia & critical care. Springer, New York; 2012. p. 709–18.

    Google Scholar 

  63. Hadjistavropoulos T, Herr K, Prkachin KM, Craig KD, Gibson SJ, Lukas A, et al. Pain assessment in elderly adults with dementia. Lancet Neurol. 2014;13(12):1216–27.

    Article  Google Scholar 

  64. Fong HK, Sands LP, Leung JM. The role of postoperative analgesia in delirium and cognitive decline in elderly patients: a systematic review. Anesth Analg. 2006;102(4):1255–66.

    Article  Google Scholar 

  65. Canet J, Raeder J, Rasmussen LS, Enlund M, Kuipers HM, Hanning CD, et al. Cognitive dysfunction after minor surgery in the elderly. Acta Anaesthesiol Scand. 2003;47(10):1204–10.

    Article  CAS  Google Scholar 

  66. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-V). 5th ed. Washington: Amer Psychiatric Pub Inc; 2013.

    Book  Google Scholar 

  67. Saczynski JS, Marcantonio ER, Quach L, Fong TG, Gross A, Inouye SK, et al. Cognitive trajectories after postoperative delirium. N Engl J Med. 2012;367(1):30–9.

    Article  CAS  Google Scholar 

  68. Robinson TN, Raeburn CD, Tran ZV, Brenner LA, Moss M. Motor subtypes of postoperative delirium in older adults. Arch Surg. 2011;146(3):295–300.

    Article  Google Scholar 

  69. Björkelund KB, Hommel A, Thorngren KG, Gustafson L, Larsson S, Lundberg D. Reducing delirium in elderly patients with hip fracture: a multi-factorial intervention study. Acta Anaesthesiol Scand. 2010;54(6):678–88.

    Article  Google Scholar 

  70. Pisani MA, Araujo KL, Murphy TE. Association of cumulative dose of haloperidol with next-day delirium in older medical ICU patients. Crit Care Med. 2015;43(5):996–1002.

    Article  CAS  Google Scholar 

  71. Rasmussen LS. Postoperative cognitive dysfunction: incidence and prevention. Best Pract Res Clin Anaesthesiol. 2006;20(2):315–30.

    Article  Google Scholar 

  72. Dokkedal U, Hansen TG, Rasmussen LS, Mengel-From J, Christensen K. Cognitive functioning after surgery in middle-aged and elderly Danish twins. Anesthesiology. 2016;124(2):312–21.

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Biomedical, Surgical and Odontoiatric Sciences, University of Milano, Milan, Italy

    Concezione Tommasino

  2. Anesthesia and Intensive Care, ASST Santi Paolo e Carlo University Hospital, Via di Rudinì 8, 20142, Milan, Italy

    Concezione Tommasino

  3. Dipartimento Area Critica A.O.R.N. dei Colli, Monaldi - Cotugno – CTO, Naples, Italy

    Antonio Corcione

  4. UOC Anestesia e TIPO, Ospedale Monaldi, Via L. Bianchi 1, 80131, Naples, Italy

    Antonio Corcione

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  1. Concezione Tommasino
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Correspondence to Antonio Corcione .

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Editors and Affiliations

  1. Department of General and Mininvasive Surgery, Cristo Re Hospital, Rome, Italy

    Antonio Crucitti

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Tommasino, C., Corcione, A. (2018). Anesthesia for the Elderly Patient. In: Crucitti, A. (eds) Surgical Management of Elderly Patients. Springer, Cham. https://doi.org/10.1007/978-3-319-60861-7_2

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  • DOI: https://doi.org/10.1007/978-3-319-60861-7_2

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