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Anesthesia and the Elderly Patient

Explore the impact of aging on surgery outcomes, comorbidities, predictors of mortality, and postoperative complications in elderly patients. Learn about cardiovascular and pulmonary changes, hypertension risks, and functional status considerations.

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Anesthesia and the Elderly Patient

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  1. Anesthesia and the Elderly Patient Sheila R Barnett, MD Assistant Professor Anesthesiology Harvard Medical School Beth Israel Deaconess Medical Center

  2. > 65y Population USA >85 y

  3. Surgery > 65 years • 35% of surgeries in USA • 16,000,000 surgeries per year

  4. RISK & COMORBIDITIES Aging involves physiological changes AND the pathophysiology of superimposed disease

  5. 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

  6. 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

  7. Preoperative conditions % 544 patients > 70 y. JAGS 2001 49:1080 344 high risk CEA patients, mean 72 y. NEJM 2004; 351:1493

  8. 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

  9. 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)

  10. 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

  11. 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

  12. Pathophysiology of Aging

  13. 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

  14. 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

  15. 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

  16. 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

  17. Diastolic Dysfunction 251 patients / CAD Age 72 y Diastolic function : E/A & deceleration time 61.5% Philip Anesth Analg 2003 ; 97 1214-21

  18. HTN Prevalence MEN WOMEN

  19. 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

  20. 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

  21. Increased Pulse Pressure • Pulse pressure = SBP –DBP • ? Possible marker for vascular disease • Low DBP also poor prognosis

  22. 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

  23. The ll/VI SEM

  24. 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

  25. 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

  26. Aspiration Risk • Reduction pharyngeal sensation • Reduction of maximal NIP • Swallowing coordination may be diminished

  27. 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

  28. CNS deficiencies • Neurotransmitter deficiencies • Integration of neuronal circuits • Fluid intelligence • Spinal cord demyelination • Decreased spinal reflexes

  29. Peripheral nervous system • Fibrosis in peripheral nerves • Less myelinated fibers • Slower nerve conduction • Diminished muscle mass

  30. CNS & Drugs • Pharmacodynamic • MAC • Altered respiratory drive & drugs • Spinal drugs • Epidural spread sensitivity

  31. Cognitive Dysfunction • Post operative delirium • Cognitive dysfunction:non-cardiac surgery • Post cardiac surgery

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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

  39. Should we do more? • Informed Consent ? • Hospitalization “unmask” marginal cognitive function • Dementia prevalent • Postoperative rehabilitation plans Cognitive Preoperative Assessments?

  40. 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

  41. Fluid homeostasis • Sodium conservation impaired • Urine concentrating ability reduced • Thirst diminished Post operative Acute Renal Failure >50% mortality in very elderly patients

  42. Body Compartments • Decline in total body water • intracellular water • plasma volume maintained • Less lean tissue & skeletal muscle mass • Increase proportion of fat

  43. Hepatic • Decrease in hepatic mass • Decrease in hepatic clearance • Less albumin • Qualitative change in protein binding • Alpha-1-glycoprotein increases

  44. Drug considerations • water soluble drugs • prolonged half life of lipophilic drugs • decreased hepatic metabolism& renal clearance • increased target organ sensitivity

  45. Risk – What Dose?

  46. Summary pathophysiology • Steady decline in organ function • Unpredictable reserve function • Increased comorbidity

  47. Reserve Function Diminished

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