Anesthesia and the elderly patient
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Anesthesia and the Elderly Patient. Sheila R Barnett, MD Assistant Professor Anesthesiology Harvard Medical School Beth Israel Deaconess Medical Center. > 65y. Population USA. >85 y. Surgery > 65 years. 35% of surgeries in USA 16,000,000 surgeries per year. RISK & COMORBIDITIES.

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Anesthesia and the Elderly Patient

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Anesthesia and the elderly patient

Anesthesia and the Elderly Patient

Sheila R Barnett, MD

Assistant Professor Anesthesiology

Harvard Medical School

Beth Israel Deaconess Medical Center


Anesthesia and the elderly patient

> 65y

Population

USA

>85 y


Surgery 65 years

Surgery > 65 years

  • 35% of surgeries in USA

  • 16,000,000 surgeries per year


Risk comorbidities

RISK & COMORBIDITIES

Aging involves physiological changes

AND

the pathophysiology of superimposed disease


30 day surgical mortality

30 day Surgical Mortality

Thoracotomy mortality over 70y: 17%

Emergency abdominal surgery > 80y: 10%

Major procedure mortality over 90y: 20 %

Jin & Chung Br J Anaesth 2001; 87:604-24


Present later

Present later

  • Review of colorectal surgery

  • Outcomes 65-74; 75-84; >85 years

  • 34 194 patients

  • Oldest patients:

    • Presented later

    • More co morbidities

    • Emergency more common

    • Survival lower

Lancet 2000; 356: 968


Preoperative conditions

Preoperative conditions

%

544 patients > 70 y. JAGS 2001 49:1080

344 high risk CEA patients, mean 72 y. NEJM 2004; 351:1493


Surgery outcomes

Surgery Outcomes

> 70y non cardiac surgery ; prospective

544 patients – age 78y

21% adverse outcome

3.7 % died

  • Adverse outcomes:

    • CVS 10%

    • CNS 8%

    • Pulmonary 5.5%

    • Renal 2.5%

    • LOS: 9 vs 4 days (p<0.001)

Predictors: Emergency

ASA Class

Tachycardia

Preop : Functional status CHF

Leung et al JAGS 2001 49:1080


Long term impact

Long term impact

  • Follow up 28 months on 517 patients - 32% deceased

    With complications: greater 3 month mortality (p 0.02)

    Predictors of mortality (p<0.0001)

    Cancer, ASA>2, CNS disease, Age, &

    Postop pulmonary and renal complications

  • Long term quality of life

    • Not impacted by postoperative outcome

    • comorbid conditions, age and new hospitalizations

Manku & Leung Anesth Analg 2003;96:583 -94 (pts 1&2)


80 year old patients

80 year old patients

26 648 > 80 y compared to 568 263 < 80 y

  • 30 day mortality all cases 8% vs. 3%, p<0.001

  • < 2% > 80 y for simple procedures

    • TURP, IH, TKR, CEA

  • > 80y 20% 1 or more complications

  • 26% mortality in patients > 80 y with complications vs. 4% if no complication

  • Mortality if > 80y with serious complications > 33%

Hamel et al JAGS 2005; 53:424


General risk factors for post operative mortality

General Risk Factors for post operative mortality

  • ASA 3 & 4

  • Major surgical procedures

  • Disease: Cardiac, pulmonary, DM, Liver and renal impairment

  • Functional status < 1-4METS

  • Anemia & Low albumin

  • Bed ridden


Anesthesia and the elderly patient

Pathophysiology of Aging


Cardiovascular

Cardiovascular

  • Peripheral

    • Decrease in arterial elasticity – vascular stiffening

    • Increase in BP

    • Increase peripheral vascular resistance

  • Ventricular

    • Increased impedance - wall hypertrophy

    • decreased compliance

    • Resting CO unchanged

    • more atrial dependence


Cardiovascular rate rhythm

Cardiovascular Rate & Rhythm

  • Conduction issues: Decline in pacemaker cells, fatty infiltration, fibrosis

  • Increase in atrial ectopy, sinus and ventricular conduction defects

  • Reduction in maximal HR – reduced response to catecholamines

  • Increased ischemic heart disease


Cardiovascular autonomic function dysautonomia of aging

Cardiovascular Autonomic Function Dysautonomia of Aging

  • Decline in beta receptor sensitivity

    • HR responses impaired

  • Increased norepinephrine levels

  • Altered sympathovagal balance - decreased HRV

  • Decreased baroreflex sensitivity


Heart failure

Heart Failure

  • 6-10% > 65 heart failure

  • 80% admissions with heart failure are >65 y

  • 40 –50 % of patients with heart failure have normal LVEF


Diastolic dysfunction

Diastolic Dysfunction

251 patients / CAD Age 72 y

Diastolic function : E/A & deceleration time

61.5%

Philip Anesth Analg 2003 ; 97 1214-21


Htn prevalence

HTN Prevalence

MEN

WOMEN


Hypertension 50 elderly

Hypertension > 50% elderly

  • Treatment usually > 140/90 mmHg

  • “High normal” 130-139/85-89 mmHg

  • VA study – Berlowitz NEJM 1998;339:1957

    • 800 males aged 65+/- 9years

    • 40% BP > 160/90 mmHg

    • Despite 6 visits /year

  • NHANES lll only 29% hypertensive population reach target goal


Complications of htn

Complications of HTN

Risk increases linearly with BP

“High normal” BP 130-139 / 85-89 mmHg also increased risk

  • Ischemic heart disease & MI

  • Stroke

  • LVH

  • Diastolic dysfunction & pulmonary edema

  • Renal failure


Increased pulse pressure

Increased Pulse Pressure

  • Pulse pressure = SBP –DBP

  • ? Possible marker for vascular disease

  • Low DBP also poor prognosis


Framingham heart study 1924 men women ages 50 79y bp components chd risk 20 y f u

Framingham Heart Study1924 men & women Ages 50-79yBP components & CHD risk 20 y f/u

CHD risk increased when SBP > 120 and DBP decreased

Franklin et al Circulation 1999; 100: 354


The ll vi sem

The ll/VI SEM


Aortic sclerosis is it really benign

Aortic Sclerosis - is it really benign?

  • >5000 echos

  • 29% (1600) with sclerosis, no obstruction

  • 5 year f/u

  • Almost 50% increase in death from CVS causes and MI in sclerosis

Otto et al, NEJM 1999


Pulmonary function and aging

Pulmonary Function and Aging

  • Thorax stiffens –

    • reduced chest wall compliance & decreased thoracic skeletal muscle mass = Increased work of maximal breathing

  • Lung volumes change – reduced inspiratory and expiratory reserve volume

  • Decrease in elastic lung recoil –closing volume increase


Aspiration risk

Aspiration Risk

  • Reduction pharyngeal sensation

  • Reduction of maximal NIP

  • Swallowing coordination may be diminished


Central nervous system

Central Nervous System

  • Cortical grey matter attrition –

    • starts in middle age

  • Cerebral atrophy – disease vs. aging

  • Increased intracranial CSF

  • CBF and auto regulation largely maintained


Cns deficiencies

CNS deficiencies

  • Neurotransmitter deficiencies

  • Integration of neuronal circuits

  • Fluid intelligence

  • Spinal cord demyelination

  • Decreased spinal reflexes


Peripheral nervous system

Peripheral nervous system

  • Fibrosis in peripheral nerves

  • Less myelinated fibers

  • Slower nerve conduction

  • Diminished muscle mass


Cns drugs

CNS & Drugs

  • Pharmacodynamic

  • MAC

  • Altered respiratory drive & drugs

  • Spinal drugs

  • Epidural spread sensitivity


Cognitive dysfunction

Cognitive Dysfunction

  • Post operative delirium

  • Cognitive dysfunction:non-cardiac surgery

  • Post cardiac surgery


Post operative delirium

Incidence 10-15% in >65y

Increased mortality

Longer hospital stay

Numerous risk factors:

Advanced age

Dementia, Depression

Anemia

Alcohol and drug withdrawal

Metabolic derangement

Acute MI

Infection

Emergency surgery

Post-operative delirium


Delirium costs

Delirium costs!

  • Per year over 2.3 million older people have delirium during hospital stay

  • 17.5 million inpatient days

  • >$ 4 billion (1994 #s) Medicare expenditure

Inoye NEJM 1999; 340:669


Postoperative cognitive dysfunction

Postoperative Cognitive Dysfunction

  • 1218 patients >60 years

  • Early 7 days 26%

  • Late 3 months 9.9% (controls 2.8%)

  • Early

    • Increasing Age

    • Duration anesthesia

    • Low education

    • Second operation

    • Infections

    • Respiratory Complications

  • Late

    • Age only

      • Moller et al Lancet 1998


  • Is it the anesthetic

    Is it the Anesthetic?

    • RCT: 262 patients

    • Knee replacement – epidural vs. general

    • 5% clinical deterioration in cognitive status at 6 months

    • No difference GA vs. regional

    • Early delirium may be marker for ongoing cognitive deterioration

    • Many similar trials and results …(but fractures & joint replacements – apples and oranges?)

    Williams Russo et al JAMA 1995; 274:44


    Confusion what can you do

    Confusion – what can you do?

    • Quick baseline assessment – date, year etc

    • Days of the week backwards

    • Honest informed consent to patient and family members

    • Careful drug (and ETOH) history

    • Avoid polypharmacy

    • Pain control


    Mild cognitive impairment

    Mild Cognitive Impairment

    • “Transitional state between the cognitive changes of normal aging and the earliest clinical features of Alzheimer's disease”

    • 10 -15% will develop Alzheimer's in a year

    • 1-2% normal elderly – Alzheimer’s

    • Role of genetics and Apolipoprotein E 4 alleles

    Petersen et al NEJM 2005; 352:2379


    Vascular patients

    Vascular patients

    • Longitudinal study – 11 years

    • 4141 men & 1681 women

    • Cognitive testing

    • Poor cognitive function Independent of age or SE class

      • Angina p 0.001

      • MI p 0.02

      • Claudication p.004

    Singh-Manoux JAGS 2003; 51:1445


    Should we do more

    Should we do more?

    • Informed Consent ?

    • Hospitalization “unmask” marginal cognitive function

    • Dementia prevalent

    • Postoperative rehabilitation plans

      Cognitive Preoperative Assessments?


    Renal function

    Renal Function

    • Progressive decrease in Renal Blood flow

    • Renal tissue atrophy - primarily cortical

      • 30% reduction in nephrons age by middle age

      • Sclerosis reaming nephrons

    • Glomerular filtration rate declines

    • Serum creatinine misleading –

      • ‘occult’ renal insufficiency


    Fluid homeostasis

    Fluid homeostasis

    • Sodium conservation impaired

    • Urine concentrating ability reduced

    • Thirst diminished

      Post operative Acute Renal Failure >50% mortality in very elderly patients


    Body compartments

    Body Compartments

    • Decline in total body water

      • intracellular water

      • plasma volume maintained

    • Less lean tissue & skeletal muscle mass

    • Increase proportion of fat


    Hepatic

    Hepatic

    • Decrease in hepatic mass

    • Decrease in hepatic clearance

    • Less albumin

    • Qualitative change in protein binding

    • Alpha-1-glycoprotein increases


    Drug considerations

    Drug considerations

    • water soluble drugs

    • prolonged half life of lipophilic drugs

    • decreased hepatic metabolism& renal clearance

    • increased target organ sensitivity


    Anesthesia and the elderly patient

    Risk – What Dose?


    Summary pathophysiology

    Summary pathophysiology

    • Steady decline in organ function

    • Unpredictable reserve function

    • Increased comorbidity


    Anesthesia and the elderly patient

    Reserve Function Diminished


    Risk reduction

    Risk Reduction

    • Beta Blockade

    • Comprehensive assessments

    • Less invasive surgery

    • ? Regional


    Beta blockade risk reduction

    Beta Blockade & Risk Reduction

    Mangano NEJM 1996;335:1713

    • 100/200 patients received Atenolol preop and for 7 days

    • Atenolol group improved survival 6 months & up to 2 y. Diabetes major risk

      Wallace Anesth 1998;88:7

    • Atenolol reduced postoperative ischemia by 30- 50%


    Anesthesia and the elderly patient

    High risk vascular patients with positive dobutamine echocardiograhpy.

    Mean age 68y

    173/ 846 positive echos

    59 bisoprolol

    61 excluded on Beta blockers /wma

    53 standard care (SC)

    Bisoprolol vs SC death or non fatal MI:

    2 (3.4%) vs 18 (34%)

    Poldermans NEJM 1999;341:1789


    Beta blockers continued

    Beta blockers continued …

    • > 600 000 patients undergoing non cardiac surgery

    • 18% received perioperative beta blockade

    • Reduction in death for those with a Cardiac Risk Index Score of 2-4

    • But possible increased risk of death for those with Cardiac Risk Index of 0 or 1

    Lindenauer et al NEJM 2005; 353:349


    Beta blocker prescription after ami by age

    Beta Blocker Prescription after AMI by Age

    45,370 patients eligible for beta blockade

    Vitagliano et al. JAGS 2004: 52:495


    Beta blockers the frail

    Beta Blockers & the Frail

    Vitagliano et al. JAGS 2004: 52:495


    Comprehensive geriatric assessments cga

    Comprehensive Geriatric Assessments (CGA)

    • 120 patients >60 y

    • CGA

      • ADLs, IADLs (Barhtel Index) , comorbidity, nutrition, MMSE

    • All undergoing thoracic surgery

    • 17% post op complications

    • Predictors –

      • Low Barthel Index

      • Surgery >300 mins

      • Dementia – low MMSE

    Fukuse Chest 2005; 127:886


    Intervention program to reduce delirium

    Intervention Program to Reduce Delirium

    • 400 patients > 70 y

    • Admitted to Intervention Ward

      • Assessment, prevention treatment education

    • Assessment day 1,3,7

    • Delirious patients in the Intervention ward

      • Shorter duration: by day 7 30% vs 60% (p 0.001 )

      • Shorter LOS: 9 vs 13 days (p 0.001)

      • Reduced mortality: 2 vs. 9 patients died (p 0.03)

    Lundstrom et al JAGS 2005:53:622


    Less invasive surgery

    Less invasive surgery ?

    Yadav et al NEJM 2004; 351:1493

    • CEA

      • 344 high risk patients average 72 y

      • Stent vs. open

      • Results showed stent as good – possible reduction in death at 1 year and at least as good or less adverse events

    • Endovascular AAA

      • 1 year perioperative survival advantage vs. open

    Blankenstein et al NEJM 2005; 352:2398


    Spinal or epidural vs general anesthesia

    Spinal or Epidural vs. General Anesthesia

    • Long a source of controversy

    • Expert opinion suggesting no significant difference in major complications or mortality

    • Meta-analysis of 141 randomized trials

    • Total of 9559 patients

    • Studied neuraxial blockade (either spinal or epidural anesthesia) vs. general anesthesia

    BMJ 2000;321:1

    Rodgers et al BMJ 2000; 321:1-12


    Meta analysis of neuraxial blockade vs general anesthesia

    Meta-Analysis of Neuraxial Blockade vs. General Anesthesia

    Rodgers et al BMJ 2000; 321:1-12


    Fractures too

    Fractures too…

    • Meta analysis

    • 15 randomized trials 2162 patients

    • In Spinal:

      • Reduction in 1 month mortality (6% vs 9%)

      • Reduction in DVT

    • Future – epidural vs LMWH and other anticoagulant strategies

    Urwin et al Br J Anesth 2000; 84(4) 450-455


    Cataracts

    Cataracts

    • Low risk

    • High volume

    • High comorbidity


    Do you ever wonder why we are in the room

    Do you ever wonder why we are in the room?

    • 1999 Survey in USA

      • 45% Ophthalmologists using topical

  • Rosenfeld in 1999

    • 1006 patients

    • 33% needed an intervention during surgery

    • No predictive factors

  • International Studies

    • 78% anesthesiologist present

    • But low topical rate

  • Reeves survey

    • ‘net preference’ for anesthesiologists


  • Stein et al nejm 2000 342 168

    Routine Testing

    No Testing

    Preoperative Medical Assessment

    EKG; CBC; Lytes, BUN, Creat & Gluc

    No tests unless new or worsening condition

    Stein et al; NEJM 2000; 342: 168

    Both groups intra and postoperative medical events 3.1/ 1000 operations


    Anesthesia and the elderly patient

    “Routine medical testing before cataract surgery does not measurably increase the safety of the surgery”

    But…

    • Preoperative evaluation done in ALL patients and ALL patients had opportunity to have testing

      Conclusion

    • Testing should directed by history and physical performed prior to surgery


    The hip fracture a morbid event

    The Hip Fracture A Morbid Event

    Is the hip fracture the sentinel event marking deterioration ?


    Hip fractures

    Hip fractures

    • 300 000 hospitalizations

    • 1 year mortality 25% - reduction life expectancy

    • Attributable cost of fracture $81 300

    • Disability significant M & M

    • US in 1997 > $20 Billion

      • Braithewaite JAGS 2003; 51: 364


    Hip fractures old people and the inevitable

    Hip fractures, old people and the inevitable …..

    • Hip fractures have high perioperative mortality 10 -25%

      Why?

      • 300 unselected hip fractures

      • All received similar multimodal treatment

      • Anesthesia epidural / strict protocol

      • Well defined rehabilitation

    Foss & Kehlet 2005; Br J Anaesth 94; 24-9


    Why did they die

    30 day mortality =13% ; >30 days 7 more died

    Combined mortality=16%

    Analysis of 47 deaths

    28% (13) unavoidable: terminal cancer, refused care

    15% (7) probably unavoidable

    34% (16) potentially avoidable; active care curtailed

    23% (11) Maximum care; ? avoidable

    Why did they die?

    Foss & Kehlet 2005; Br J Anaesth 94; 24-9


    Miscellaneous

    Miscellaneous


    Sensory changes

    Sensory Changes

    • Decreased visual acuity & dark adaptation

    • Attrition of taste buds

    • Diminished thirst sensation

    • Compromised joint perception

    • Diminished fine control of skeletal muscles


    Anesthesia and the elderly patient

    DISABILITIES COMMON

    > 80y


    Polypharmacy

    Polypharmacy

    • Adverse drug events 3 -10% admissions common

    • Elderly on multiple medications

    • 30% prescriptions & 40% of OTC drugs

    • Drugs and herbs

      • eg Ephedra alkaloids -ma huang

      • Adverse Events : HTN, palpitations, strokes, seizures


    Etoh elderly

    ETOH & Elderly

    Alcohol and Drug prescription problems affect 17% of older Americans

    • Increase sensitivity & decrease in tolerance

    • Decrease lean body mass & TBW = higher concentration

    • Decrease in alcohol dehydrogenase may slow metabolism


    Social issues

    Social Issues

    • Increase in disability

    • Lack of a spouse

    • Cognitive and sensory problem

    • Scheduling - a family commitment


    Challenges elderly

    Challenges & Elderly

    • heterogeneous population

    • unpredictable organ reserve

    • disease burden

    • atypical disease presentation

    • emergent procedures

    • minor complications can rapidly escalate


    Geriatric graphs

    Geriatric Graphs

    Disease or badness

    Age years

    Age years

    Function


    Future

    Future ?

    • Cognitive Preoperative assessment

    • Functional outcomes

    • Perioperative interventions


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