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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

Anesthesia and the Elderly Patient

Sheila R Barnett, MD

Assistant Professor Anesthesiology

Harvard Medical School

Beth Israel Deaconess Medical Center

slide2

> 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
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

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

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
summary pathophysiology
Summary pathophysiology
  • Steady decline in organ function
  • Unpredictable reserve function
  • Increased comorbidity
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%
slide53
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

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

slide66
“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

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
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
ad