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Dr. Tushar Chokshi M.D. (Anesthesia)
Physiological Changes &
Pre-operative Evaluationin
Geriatric Patients
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Lecture outline
Introduction
Normal physiological changes associated with ageing and its Anaesthesia Implication
Pre-operative Assessment Pharmacokinetics and Pharmacodynamics in
the elderly
Take Home Message
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Who are Geriatric PatientsMost of the world countries have accepted the chronological age of 65 and more as a definition of geriatric patients ( Three Groups)Elderly ------ Age 65 to 74Aged -------- Age 75 to 84Very Old ---- Age 85 and more
Old age is not a disease
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Realities for the geriatric patients in Health
* In India around 200 millions (15 %) people are > 65 years* They account for almost half of hospital care days* 25-35% surgical cases and procedures done on this age group* Life expectancy in India now 70-72 yrs* Medical diseases are most common in this group * Demographical data indicate the elderly people are most
rapidly growing in population• Use of health care services by elderly disproportionately
higher than younger patients• The mortality rates for patients aged 80-84 is 3 %, 85-90 is 6 %
and above 90 year is 10 % in major surgeries
But all geriatric patients are not created equal !
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Guinness Book of World Records
( Anesthesia given to Oldest Patient)
Laurie Randall
Age -102 years
Surgery – Revision of Hip Replacement
Anesthesia – Epidural
Duration – 2 Hours
Pinderfields Hospital in Wakefield, West Yorks, UK
2 February 2012
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Age-Related Physiological Changes Three Groups of Physiological
Changes
1) Changes in autonomic functions and cellular homeostasis e.g. temperature, blood volumes and Endocrine changes
2) Reduction in organic mass e.g. brain, liver, kidneys, bones and muscles
3) Reduction in organic functional reserve e.g. lungs and heart
Systems Affected
• Cardiovascular system• Respiratory System• Genitourinary System• Gastrointestinal System• Endocrine System• Skin and Musculoskeletal System• Nervous System• Body temperature regulation• Immune System• Psychological Changes
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Cardio-Vascular Changes • Heart – Cardiac output Decrease 1 % per year after 30 years
of age (at 80 year age CO is half that of a 20 year old person)• Blood Pressure – BP increase 1 mm of hg every year after 50
years as a normal consequence of aging. Systolic will increase and Diastolic remains unchanged or increase. ( Who data says around 50 % are Hypertensive in geriatric age group )
• Arteriosclerosis and Coronary Artery DiseaseThickening of arterial walls and Loss of elasticityLoss of SA node cells causing slowed conductionMyocytes death without replacement leading to increase risk of myocardial infarction
• Decreased response to beta-receptor stimulation• ECG Slightly increased PR, QRS and Q-T intervals
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Changes and its Effects
Changes
• Arterial wall thickening, stiffening & decrease compliance
• Left ventricular and atrial Hypertrophy
• Sclerosis of atrial and mitral valves• Decrease Beta adrenergic
response• Decrease baroreceptor sensitivity• Decrease SA node automaticity• Diastolic Dysfunction
Effects
• Decrease exercise tolerance leading to easy fatigability
• Coronary artery Disease• Congestive Heart failure• Risk of arrhythmias• Diminished peripheral pulse
and cold extremities• Increased blood pressure• Postural Hypotension
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Thickened arterial wallNarrow lumen
Sclerosis of atrial and mitral valves
SA nodeDysfunction
Increased Stiffness and Endothelial Dysfunction
arrhythmia
DiastolicDysfunction
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Anaesthesia Implication
• Hypotension and Bradycardia should be kept in mind during induction• For emergency Anesthesia BP up to 180/110 mm of hg should be allowed• Heart Rate up to 50 at rest is allowed for induction• Minor ECG changes are not threatening for anesthesia induction• Ejection Fraction up to 45 % is normal for geriatric age group without any symptoms• Use of Beta blockers and Anti platelets in pre operative period gives more cardio stability in old heart
Remember old heart can not compensate decrease CO or increase heart rates
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Reduced gas ExchangeIncrease Wall RuptureAlveolar Size increase
Alveolar changes in Older Lungs
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Changes and its effects
Changes• Decrease respiratory muscle
strength and elasticity• Stiffer chest wall, AP diameter
increase• In alveolar oxygen, no change• In arterial oxygen, progressive
decrease• Ventilation perfusion mismatch• Every year, 25 ml of decreased
VC and 25 ml increased RV after 20 years of age
Effects• Functional capacity declines• Decrease cough reflex and
airway ciliary action • Frequent airway collapse• Reduced Compliance• Snoring and Sleep apnea
common• Higher chances of aspiration• Increased risk of infection and
bronchospasm with airway obstruction
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Anesthetic Implications
• Advice to stop smoking at least 2 weeks before planned surgery and anesthesia
• Proper Antibiotic & Anti-aspiration prophylaxis• Educate older people for deep breathing and
coughing reflex preoperatively • Oxygen-Oxygen-Oxygen therapy in Pre-Intra-
Post anesthesia period• Avoid or reduce doses of Opoids
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Genitourinary System Changes Kidneys
--Gradual decrease in volume and weight of kidneys with aging--Renal blood flow decrease, GFR decrease--Decrease in total glomeruli leading to age related decrease in creatinine
clearance (no change in serum creatinine with advance age )--Age related increase in blood urea nitrogen
Bladder--Urinary incontinence found in almost 20 % population more than 65
years--Capacity of bladder decrease & late sensation leading to overflow
incontinenceProstate
--Enlargement of prostate in 90% male more then 65 years age, but only 10 % have symptomatic hyperplasia require surgery
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Anesthesia Implication
• Age related Renal changes interferes with the excretion of anesthesia drugs
• Because of bladder and prostatic changes urinary catheterization is prime importance in major anesthesia and surgery
• Renal insufficiency, dehydration and renal failure common in elderly, so prompt actions to be taken
• Geriatric patients allowed clear fluid at least two hours before anesthesia
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Gastrointestinal System ChangesEsophagus --Decrease in strength of muscles of mastication, taste and thirst
--Presbyesophagus ( disturbances of esophageal activity )--Decrease peristaltic movement & delayed transit time
leading to dysphagia--Relaxed lower sphincter leading to chances of aspiration
Stomach--Atrophic gastritis , which increase with age--Increase heart burn in because of chronic enterogastric bile reflux
Colon--Decrease in colonic motility leading to constipation and
increase storage capacity--Laxative abuse is very common
Liver and Billiary Tract-- Decrease in liver weight and blood flow by 20 %, but no change in
Liver Function Tests--Catalytic enzymes activity decrease--Synthesis of protein binding and coagulation factors decreases-- Drug metabolism is slow in old age group-- Billiary tract disease are common
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Anesthetic Implications
• Correct Fluid, Electrolytes and Nutritional imbalance accordingly because of GUT changes
• Increased risk of gastric aspiration(PPI cover) and NSAID induce ulcers (avoid)
• Keep in mind about constipation & complain of constant abdominal disturbance Post-Op
• Decrease metabolism of anesthesia drugs and risk of adverse drug reactions because of liver changes
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Endocrine System Changes Pancreas (Glucose Homeostasis)
--Progressive deterioration in the number and function of beta cells, but no decline in Insulin level-- The average fasting glucose level rises 6 to 14 mg/dL for each 10 years after age 50. --Decrease glucose tolerance
Thyroid --Tendency for hypothyroidism-- No change in Thyroid Function Tests
Parathyroid Gland--No atrophy of Gland, but some fat deposition--After 40 years PTH level in women increase leading to bone loss problems (calcium and vitamin D reduction)
Adrenal glands--No atrophy, but increase fibrous tissue--Secretions of adrenal medulla increase(psychosomatic dz)
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Anesthesia Implication
• Hyperglycemia increase the mortality and morbidity in old age , because of late diagnose of DMHyperglycemia and Hypoglycemia both not tolerated
• Accepted level of FBS is between 80 – 120 mg/dl or HbA1C less than 7 (always ask for HbA1C)
• Discontinue metformine and sulfonyl ureas night before and day of surgery( due to increase chance of MI in hypovolemic and reserved cardiac functions in old age)
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Skin and Musculoskeletal System Changes
Skin --Epidermis : Atrophy around face, neck, chest and extensor surface of limbs--Because of epidermis loss, prone for decubitus ulcers--Dermis : Skin loses its elasticity resulting wrinkling and sagging of sagging
of skin--Decreased sensitivity to pain and pressure
Skeletal
--Degenerative Joint Diseases causing disability--Pain response is severe --30 % Muscle mass reduced leading to decrease peripheral metabolism
of drugs, Low BMR due to weight loss --Adipose tissue increase gradually--Edentulism ( Gradual teeth loss)--Osteoarthritis and Osteoporosis--Inability to chew and poor oral health
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Anesthetsia Implication• Consider difficult IPPR and Intubation• Body temperature to be cared during anesthesia
period. Avoid excessive cold temperature in OT and preferably cover geriatric patient fully.
• Avoid pressure ulcers and padding of pressure points• Handle all geriatric patients carefully to avoid
fractures and excessive manipulation during different surgical position (Handle With Care)
• Pre operative transfer of geriatric patient from ward to OT is always in presence of medical attendant (in wheel chair or in supine position)
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Nervous system Changes
As the nervous system is the target for virtually every anesthetic drug, so age related changes in nervous system have essential implications for
anesthetic management
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Neurologic Changes
• Weight of brain decrease• Loss of brain cells• Blood flow to brain decrease• State of confusion• Interference with
ThinkingReadingInterpretingRemembering
• Sense of smell, Vision and hearing diminish
• Impairment of Cognitive functions increase with age advancement
• Problems in physiological regulation of Hypotension and temperature
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Anesthesia implication
• Difficulty in Communication, Cooperation & Coordination
• Cognitive functions to be noted pre operatively• Old patients take more time to recover from GA
especially if they were disoriented preoperatively• Old Patient experience varying degrees of delirium• Sensitive to centrally acting anticholinergic agents • The % of delirium is less with regional anesthesia,
provided there is no additional sedation• Dose requirements for local, general & inhalation
anesthetics are reduced
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Temperature Regulation ChangesElderly are prone to hypothermia because of• Lower body metabolism• Vasodilatation of skin blood flow• Decrease thermo genesis capabilityleading to– Shivering – Increase metabolic demand– Slow drug metabolism – Increase risk of myocardial ischemia
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Anesthesia Implication
• Hypothermia should be avoided• Shivering will increase oxygen demands• To prevent heat loss
- Use warm solutions- Use warm Blankets- Keep OT temperature warm
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* Slow to respond. * Increases risk of getting sick. * An autoimmune disorder may develop. * Healing is also slowed in older persons. * The immune system's ability to detect and correct cell defects also declines. * increase in the risk of cancer.
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Psychological Changes
• Loss of physical strength and abilities
• Loss of mental abilities (confusion, dementia)
• Loss of relationships when companions or friends die
• Loss of self-esteem• Loss of body image• Loss of independence• Loss of control over life
plans and lifestyletmc
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Anesthetic Implications
* Geriatric patients with psychological changes are difficult to handle for history taking & physical examination.* Anesthesiologist should calm,
cooperative and always take help of family member in pre assessment.
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THE CAT IN THE HAT
I CAN NOT SEEI CAN NOT PEE
I CAN NOT CHEWI CAN NOT SCREW
OH MY GOD, WHAT CAN I DO ?
MY MEMORY SHRINKSMY HEARING STINKS
NO SENSE OF SMELLI LOOK LIKE HELL
MY MOOD IS BAD – CAN YOU TELL ?
MY BODY IS DROOPING HAVE TROUBLE WITH POPPING
THE GOLDEN YEARS GONEWITH LOSS OF BONE
I AM EVERY WHEREHANDLE WITH CARE
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Pre-operative evaluation
1) Complete History
2) Physical Examination
3) Laboratory Investigations
4) Tailor made Anaesthesia plan according to surgery
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BEST PRACTICES FOR COMMUNICATION WITH OLDER ADULTS
1) Anaesthesiologist should make the assessment face-to-face, allowing the patient to see lip movements when speaking; this is particularly important if the patient has a hearing problem.
2) Voice tone should be clear, slow and slightly louder than usual.
3) The anaesthesiologist should understand by asking leading questions from the patient or caregiver or companion.
4) One question should be asked at a time, allowing sufficient time for patient responses. Even healthy older adults may take a little longer to process a question and frame a response.
5) Communication should be modified to match the individual’s learning style and incorporate language the patient uses, avoiding complex medical
terminology, acronyms, and abbreviations.
6) If the patient has cognitive impairment, assessment questions should be verified with the assistance of the family members or primary caregiver.
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How to communicate with deaf old patients
50 % geriatric patients are having hearing problem. It is sometimes difficult to
communicate with them.
So, our medical stethoscope will help us by reversing the ends.
Patients will communicate very nicely.
Simple but very useful way .
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Complete medical history
History• CVS and RS complaints
present and past• Routine activities• Mental & Physical status• Dependency• Associated Diseases• Drug history/Polypharmacy• BMI / Nutrition• Past history Op/Ane. experience• Any alternative medicine• Allergy• Social and Family history
• Any habits Tobacco/smoking/drinks• Sleep patternsAlways see for
depressionmalnutritionimmobility dehydrationDenturePace makerAny joint replacementAny anti depressant Rx
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So again to repeat, in Assessment
• See whether geriatric patient is able to perform mental, social and physical activities
• All patients must be examined in presence of family or friends or guardian
• Always see for polypharmacy because these group are suffering from 2 or 3 systemic dis.
• Note the cognitive functions status, to compare pre and post op changes
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Different Risk factor Scales are available for
Pre-Assessment
APCHE (Acute Physiological and Chronic Health Evaluation) for critically ill patientsPOSSUM (Physiological and Operative
Severity Score for enumeration of Mortality and Morbidity) for surgical pts.
Goldman scales of Cardiac risk for non-cardiac surgery
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General Physical Examination
• Physical examination of old patient always to be done in warm area
• General appearance• Head to Toe Examination for pressure points,
Joints, hearing and vision impairment• Height / Weight• Neck mobility, any spine deformity, teeth loss
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Physical Examination
EXAMINE FOR• Vital signs• CVS and RS system• Oxygen Saturation• Pain Threshold • Breathing pattern• Breath Holding Time• Clock Drawing Test• Trail Making test
SEE FOR• Difficult Intubation• Difficult regional anae.• Difficult nerve blocks• Difficult IV line• Weight for BMI• Drugs regularity• Relatives’ attitude and
responsibility
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Investigations
RoutineComplete Haemogram
FBS/HbA1CECG
X-Ray ChestRenal functions
LFTs with proteins(all above investigations are
must for routine anesthesia administration)
SpecialAccording to Positive
medical history & diseaseEchocardiography for CVS
Spirometry for RSSonography for GIT & KUB
Other Tests according to Systems affected
e.g. CVS/RS/GIT/URINARY
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So, after assessment of geriatric patient• It is very important to determine the patient’s
status and physiologic reserve in the pre-anesthetic evaluation.
• The risk from anesthesia is more related with the presence of co-existing disease than with the age of the patient.
• The condition should be optimized before surgery with good nutrition, pharmacological support, System wise and done without delay, as long delays increase morbidity rates.
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In Geriatric Patients
• The circulating level of albumin decreases. (binding protein for acidic drugs)
• While the level of α-1 acid glycoprotein increases. (binding protein for basic drugs)
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And• The decrease in total body water leads to a reduction in the central
compartment and increased serum concentrations after a bolus administration of a drug.
• Increase in body fat results in a greater volume of distribution of
drugs and prolonging action.• Aging effect on hepatic and renal functions drug metabolism will be altered
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So for, Dose and Duration of Drugs
One has to remember thatAltered body composition in old age leads -- decrease blood volume-- decrease muscle mass-- decrease plasma proteins-- decrease circulatory time-- decrease metabolism & clearance
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Doses of Anesthetic Agents• Sedations – Decrease• Induction Agents – Decrease (almost 50 % )• Opioids – Decrease ( Remifentanyl is most potent)• Muscle Relaxants – No change• Inhalation Agents – Reduce MAC ( Ideal is 1.5 MAC )• Local Anesthetics – DecreaseNote :
Ideal inhalation agent for old age is DesfluraneIdeal muscle relaxants for old age is AtracuriumInduction Agents are used according to pre-assessment and risk of surgery
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Regional & Peripheral Nerve Blocks
• The duration of analgesia may be prolonged with age advancing on the baricity, dose and strength of the local anesthetic solution
• When GA carries great risk for the patient, Regional Anesthesia or Nerve Blocks provide an excellent solution
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To Sum-Up Pharmacology of Anaesthesia drugs
• The elderly are more sensitive to anesthetic agents and generally require smaller doses for the same clinical effect, and drug action is usually prolonged.
• One arm brain circulation is about 20 seconds and drugs to reach their maximum effect requires 3 to 4 circulation. And in old age this time is up to 90 seconds. So drug dose requirement is less.
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Some words for Fluid administration --Elderly patient compensates poorly for
hypovolemia & over transfusion.--After one liter of infusion, better replace blood
loss with blood transfusion--Liberal oral intake of fluids allowed 2 to 3 hours
preoperatively --Always keep in mind about elderly
compromised heart, poor organ perfusion and reduction in GFR for IV fluid administration
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Decreased Physiologic
Reserve
ProviderLack of
Knowledge
Increased Preexisting
Diseases
High incidence of morbidity & mortality in old ageBecause of
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Elderly patients are vulnerable and particularly sensitive to the stress of Trauma, Hospitalization,
Surgery and Anesthesia.Anesthesiologists must Remember and Do
* Understanding old age physiology and pre operative management of coexisting disorders
* Meticulous preoperative assessment of organ function and reserve * Careful drug selection & dosage titration,* Careful fluid therapy* Selection between RA & GA
* Proper psychological preparation & Management * Good post operative pain control