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Anaesthesiology
Anesthesia for the Older Patient
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
20 sections · 194 slides
Overview
- Scope of this topic
- Roadmap of the topic
- Core messages
Demographics and Economics of Aging
- Growth of the older population in the United States
- Scale of population aging
- Past and projected United States population by age group
- Hospital and operating room use by older patients
- Cost of care for older adults
The Process of Aging
- Definition of biologic aging
- Three-tier hierarchy of aging mechanisms
- Primary mechanisms of aging
- Antagonistic mechanisms of aging
- Integrative mechanisms of aging
- COVID-19 and vulnerability in older patients
- Life span versus healthspan
Functional Reserve and Frailty
- Functional reserve
- Definition of frailty
- Frailty, disability, and comorbidity compared
- Two ways to conceptualize frailty
- Prevalence of frailty in older adults
- Outcomes in frail surgical patients
- Frailty phenotype criteria
- Frailty index by deficit accumulation
- Frailty tools most studied in surgical patients
- Reading the frailty screening table
- Frailty screening tools
The Physiology of Organ Aging
- Common age-related changes in physiology by organ system
- Reading the organ-by-organ summary
Body Composition, Liver, and Kidney
- Changes in body composition with age
- Hepatic aging
- Renal aging
- Glomerular filtration rate and comorbid disease
- Sodium and water handling in the aged kidney
Central Nervous System Aging
- Structural and neurotransmitter changes in the aging brain
- Cognitive change with normal aging
- Increased anesthetic sensitivity of the aging brain
- Age-related decrease in minimum alveolar concentration
Drug Pharmacology and Aging
- Pharmacodynamic versus pharmacokinetic causes
- Vessel-rich and vessel-poor tissue groups
- Reasons a bolus has a greater initial effect in older patients
- Redistribution and termination of drug effect
- Pharmacokinetic effect of aging on drug metabolism
- Mechanisms of reduced clearance in older patients
- Effect of age on the elimination half-life of diazepam
- Context-sensitive half-time
- Age effects on neuromuscular blocking drugs
- Reading the drug dosing table
- Effect of age on drug dosing
- Effect of age on drug dosing (continued)
- Effect of age on drug dosing (continued)
- Effect of age on drug dosing (continued)
- Effect of age on drug dosing (continued)
- Pharmacologic basis for age-adjusted dosing
- Pharmacologic basis for age-adjusted dosing (continued)
Cardiovascular Aging
- Major cardiovascular changes with age
- Autonomic changes and blood pressure lability
- Blunted response to catecholamines
- Arterial stiffening and systolic hypertension
- Diastolic dysfunction
- Dependence on ventricular filling
- Venous stiffening and postural hypotension
- Conduction system changes and arrhythmias
- Loss of ischemic preconditioning
- Pulse pressure as a marker of vascular age
Pulmonary Aging
- Chest wall stiffening and diaphragm flattening
- Loss of lung elastin and increased compliance
- Small airway tethering and closing capacity
- Spirometry changes with aging
- Blunted ventilatory drive with age
- Upper airway obstruction and sleep-disordered breathing
- Cough, swallowing, and aspiration risk
Thermoregulation and Aging
- Normal defences against cold
- Impaired thermoregulation in older patients
- Anesthetic effects on thermoregulatory thresholds
- Consequences of perioperative hypothermia
Perioperative Management Framework
- The Age-Friendly Health System 4-Ms framework
- Geriatric Surgical Verification Program
- Enhanced recovery and the perioperative surgical home
Preoperative Evaluation and Preparation
- Guidelines for preoperative geriatric assessment
- Goals of preoperative planning in older patients
- Advance directives and end-of-life considerations
- Functional recovery after major surgery
- Perioperative neurocognitive disorders nomenclature
- Preexisting cognitive impairment and consent
- Recommendations for perioperative brain health
- Malnutrition and dehydration in the very old
- Reading the preoperative best-practice table
- Preoperative best practice guidelines for older adults and implementation strategies
- Preoperative best practice guidelines for older adults and implementation strategies (continued)
- Preoperative best practice guidelines for older adults and implementation strategies (continued)
- Preoperative best practice guidelines for older adults and implementation strategies (continued)
- Beers Criteria medications in perianesthesia care
- Common perianesthesia medications to avoid
- Common perianesthesia medications to avoid (continued)
- Common perianesthesia medications to avoid (continued)
- Common perianesthesia medications to avoid (continued)
- Prehabilitation
- Prehabilitation and postoperative functional trajectory
- Components of modern prehabilitation programs
- Cognitive prehabilitation
Immediate Preoperative and Intraoperative Management
- Immediately before the operating room
- Induction of general anesthesia in older patients
- Limiting hypotension at induction
- Spinal versus general anesthesia for hip fracture
- Total intravenous versus volatile anesthesia
- Hemodynamic effects of anesthesia maintenance
- Hemodynamic response to spinal anesthesia in older men
- Vasoconstrictors versus volume for intraoperative hypotension
- Ventilation strategy in older patients
- Residual neuromuscular blockade in older patients
- Sugammadex for reversal in older patients
- Sugammadex compared with neostigmine
- Electroencephalographic monitoring: the ENGAGES trial
- Anesthetic depth: the BALANCED trial
- Delirium findings in the BALANCED subanalysis
- The SHARP trial of spinal with BIS-guided sedation
- Current position on processed EEG monitoring
- Analgesic drug choices in older patients
- Dexmedetomidine and gabapentinoids
Postoperative Care
- Goals of the immediate postoperative period
- Routine delirium screening after surgery
- Tools for diagnosing delirium
- Nonpharmacologic delirium risk reduction
- Challenges of postoperative analgesia in older patients
- Barriers to assessing pain in older patients
- Adjuncts and regional analgesia
- General postoperative geriatric care measures
- Integrated care models for older inpatients
Perioperative Complications
- Increased complication risk in older patients
- Factors of normal aging that increase adverse outcome risk
- Anesthetic sensitivity and long-term outcome
- Intraoperative hypotension and adverse outcomes
- Interaction between age and comorbid disease
- Cardiac and pulmonary complications compared
- Effect of age on selected perioperative complications and associated mortality
- Reading the complication and mortality data
- Incidence and risk factors for perioperative stroke
- Timing, mechanism, and mortality of perioperative stroke
Perioperative Neurocognitive Disorders
- Classification of perioperative neurocognitive disorders
- Why the nomenclature was changed
- Diagnostic criteria for neurocognitive disorders
- Animal evidence for anesthetic neurotoxicity
- Burden of postoperative delirium
- Risk factors for postoperative delirium
- Precipitating factors for delirium
- Risk factors, features, and outcomes of delirium
- The ISPOCD study of postoperative cognitive dysfunction
- Twin study of surgery and cognitive function
- Long-term cognitive outcome after surgery
- Relationship between delirium and later cognitive decline
- Practical conduct of anesthesia in older patients
The Future
- Priorities for future research
- Implementation strategies for risk mitigation
- Healthcare disparities in older surgical patients
Summary
- Key points on aging and reserve
- Key points on perioperative management
- Key points on analgesia and complications
- Practical checklist for the older surgical patient
References
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- References (continued)
- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition