Topic: Elderly Patient Faculty: Medicine Course: BSc ATOT - 2nd year Subtopics: - Physiological changes seen in elderly - Comorbidities in elderly - Anesthetic challenges in elderly - Preoperative evaluation - Intraoperative care - Postoperative care - Postoperative Cognitive Dysfunction(POCD)

1. Elderly patient
Dr. Salman Ahmad Ansari
Kanachur Institute of Medical Sciences

2. Contents
● Physiological changes seen in elderly
● Comorbidities in elderly
● Anesthetic challenges in elderly
● Preoperative evaluation
● Intraoperative care
● Postoperative care
● Postoperative Cognitive Dysfunction(POCD)

3. Physiological changes in elderly
- Changes seen in all organ systems
- Cardiac output decreases
- BP increases
- Arteriosclerosis
- Lungs: impaired gas exchange, decrease in VC and slower
expiratory flow rate
- Kidneys: decreased creatinine clearance(but creat level
remains constant)

4. - Intestine: changes in motility
- Elevation of blood glucose
- Osteoporosis
- Skin: decreased tone and elasticity
- Decreased lean body mass
- Joint degeneration
- Hearing loss, vision loss
- Metabolism is altered - different drug doses needed

5. Comorbidities seen in elderly
● Hypertension
● Diabetes
● Heart diseases
● Stroke
● Chronic lung disease
● osteoarthritis
● Dyslipidemia
● Carcinomas
● Falls
● Frailty

6. Hypertension
- Most common chronic disease in elderly
- Isolated systolic HTN
- Non-pharmacological strategy
- Weight reduction
- Dietary sodium reduction
- Physical activity
- Moderate alcohol consumption
- Dash diet
- Pharmacological strategy: depends upon comorbidities
- Thiazide diuretics are preferred
- ACEIs, ARBs
- Combination therapy
- Start with lowest dose and gradually increase

7. Osteoarthritis
- Second most common chronic condition
- Common cause of chronic pain and disability
- Joint replacement surgery
- Pain management

8. Diabetes mellitus
- Higher risk of macro and microvascular complications
- Treatment:
- Lifestyle modification
- Weight loss, if obese
- Diet modification
- Avoid sugary drinks
- Oral hypoglycemic agents:
- metformin, sulfonylureas and meglitinides - risk of hypoglycemia
- thiazolidinedione(pioglitazone): low risk for hypoglycemia
- Insulin: fear of hypoglycemia

9. Osteoporosis
- Increased risk of bone fractures

10. Falls
- Major cause of morbidity and disability
- Decrease in lower limb strength, vision problems, balance,
polypharmacy
- Fall prevention programme:
- Physical activity
- vitamin D supplementation
- balance exercise
- home safety assessment

11. Polypharmacy
- concomitant use of five or more medications by a single
patient.
- When taking five medications, the risk of an adverse drug
event or drug-drug interaction is very high.
- polypharmacy increases the risk of falls, disability

12. Anesthetic challenges in elderly
- In aging, there are changes in structural and functional capacity of
organs and tissues
- More sensitive to anesthetic agents
- Lower dose required to achieve desired clinical effect
- Drug effect is often prolonged
- Goal of perioperative care in geriatric population is to speed
recovery and avoid functional decline
CVS:
- Fluid administration has to be done very carefully
- due to diastolic dysfunction and decreased vascular compliance,

13. Respiratory:
- Decrease in FEV1, PaO2 due to V/Q mismatch
- When shifting to post op facility, they should be transferred with
oxygen via nasal cannula
- Postop respiratory complications are more common
Renal:
- Renal blood flow decreases with age
- S. creatinine is stable
- Impairment of sodium handling, concentrating ability and
diluting ability - risk of dehydration and fluid overload
- Risk of acute renal failure in postop period

14. Nervous system:
- Dose requirement for local and general anesthetics is reduced
- Elderly patients take more time to recover from general anesthesia
- delirium
Pharmacology:
- Changes in drug metabolism
- Drug action is prolonged
- Inhalation drugs: decreased minimum alveolar anesthetic
concentration(MAC)
- Opioids: require less doses for pain relief
- Neuromuscular blockers(relaxants): prolonged duration of action
- Peripheral nerve blocks: analgesia is prolonged

15. Preoperative evaluation
- Complete and thorough history, examination and investigations
- Risk depends more on presence of comorbidities than the age of
the patient
- Determine patient’s status and estimate physiologic reserve in
preanesthetic evaluation
- Optimise the condition before surgery
- Assess cognitive status: mini mental score
- Elderly patients require lower doses of premedication
- Anticholinergics: not needed usually
- H2 antagonists(ranitidine): to reduce risk of aspiration

16. Intraoperative care
- Preoxygenation and prewarming
- Follow ASA standards for basic anesthesia monitoring
- Be present and vigilant throughout the surgery to monitor stability
- Monitors for detecting changes in oxygenation, ventilation,
circulation and temperature
- Optimal positioning, avoid causing skin tears, apply extra padding
- General anesthesia and age are associated with hypothermia -
maintain normothermia
- For general anesthesia: titrate drug doses & prefer short-acting
drugs
- Fluid management: avoid both overhydration and dehydration
- Vasopressors and fast-acting antihypertensives to maintain safe BP

17. Postoperative care
- Oxygen therapy: transport patient to postop with oxygen via
nasal cannula
- Pulmonary complications of major importance
- Postop analgesia
- Shorter hospitalisation should be the aim
- DVT prophylaxis: early mobilisation, compression stockings
- Watch for post op delirium and postoperative cognitive
dysfunction(POCD)

19. Postoperative Cognitive Dysfunction(POCD)
- Can present weeks or months postoperatively
- It resembles dementia
- Impairments seen in mood, memory, learning, language,
behaviour and motor function
- Treatment: correction of physiological parameters, good pain
relief and geriatrician involvement

20. References:
- Anesthesia for the elderly
- Anesthetic Considerations in the Geriatric
Population
- Anaesthesia in the Elderly
Questions:
salman.s.ansari92@gmail.com
For PPT, scan: