Topic: Elderly Patient
Faculty: Medicine
Course: BSc ATOT - 2nd year
Subtopics:
- Physiological changes seen in elderly
- Comorbidities in elderly
- Anesthetic challenges in elderly
- Preoperative evaluation
- Intraoperative care
- Postoperative care
- Postoperative Cognitive Dysfunction(POCD)
2. Contents
● Physiological changes seen in elderly
● Comorbidities in elderly
● Anesthetic challenges in elderly
● Preoperative evaluation
● Intraoperative care
● Postoperative care
● Postoperative Cognitive Dysfunction(POCD)
3. Physiological changes in elderly
- Changes seen in all organ systems
- Cardiac output decreases
- BP increases
- Arteriosclerosis
- Lungs: impaired gas exchange, decrease in VC and slower
expiratory flow rate
- Kidneys: decreased creatinine clearance(but creat level
remains constant)
4. - Intestine: changes in motility
- Elevation of blood glucose
- Osteoporosis
- Skin: decreased tone and elasticity
- Decreased lean body mass
- Joint degeneration
- Hearing loss, vision loss
- Metabolism is altered - different drug doses needed
10. Falls
- Major cause of morbidity and disability
- Decrease in lower limb strength, vision problems, balance,
polypharmacy
- Fall prevention programme:
- Physical activity
- vitamin D supplementation
- balance exercise
- home safety assessment
11. Polypharmacy
- concomitant use of five or more medications by a single
patient.
- When taking five medications, the risk of an adverse drug
event or drug-drug interaction is very high.
- polypharmacy increases the risk of falls, disability
12. Anesthetic challenges in elderly
- In aging, there are changes in structural and functional capacity of
organs and tissues
- More sensitive to anesthetic agents
- Lower dose required to achieve desired clinical effect
- Drug effect is often prolonged
- Goal of perioperative care in geriatric population is to speed
recovery and avoid functional decline
CVS:
- Fluid administration has to be done very carefully
- due to diastolic dysfunction and decreased vascular compliance,
13. Respiratory:
- Decrease in FEV1, PaO2 due to V/Q mismatch
- When shifting to post op facility, they should be transferred with
oxygen via nasal cannula
- Postop respiratory complications are more common
Renal:
- Renal blood flow decreases with age
- S. creatinine is stable
- Impairment of sodium handling, concentrating ability and
diluting ability - risk of dehydration and fluid overload
- Risk of acute renal failure in postop period
14. Nervous system:
- Dose requirement for local and general anesthetics is reduced
- Elderly patients take more time to recover from general anesthesia
- delirium
Pharmacology:
- Changes in drug metabolism
- Drug action is prolonged
- Inhalation drugs: decreased minimum alveolar anesthetic
concentration(MAC)
- Opioids: require less doses for pain relief
- Neuromuscular blockers(relaxants): prolonged duration of action
- Peripheral nerve blocks: analgesia is prolonged
15. Preoperative evaluation
- Complete and thorough history, examination and investigations
- Risk depends more on presence of comorbidities than the age of
the patient
- Determine patient’s status and estimate physiologic reserve in
preanesthetic evaluation
- Optimise the condition before surgery
- Assess cognitive status: mini mental score
- Elderly patients require lower doses of premedication
- Anticholinergics: not needed usually
- H2 antagonists(ranitidine): to reduce risk of aspiration
16. Intraoperative care
- Preoxygenation and prewarming
- Follow ASA standards for basic anesthesia monitoring
- Be present and vigilant throughout the surgery to monitor stability
- Monitors for detecting changes in oxygenation, ventilation,
circulation and temperature
- Optimal positioning, avoid causing skin tears, apply extra padding
- General anesthesia and age are associated with hypothermia -
maintain normothermia
- For general anesthesia: titrate drug doses & prefer short-acting
drugs
- Fluid management: avoid both overhydration and dehydration
- Vasopressors and fast-acting antihypertensives to maintain safe BP
17. Postoperative care
- Oxygen therapy: transport patient to postop with oxygen via
nasal cannula
- Pulmonary complications of major importance
- Postop analgesia
- Shorter hospitalisation should be the aim
- DVT prophylaxis: early mobilisation, compression stockings
- Watch for post op delirium and postoperative cognitive
dysfunction(POCD)
18.
19. Postoperative Cognitive Dysfunction(POCD)
- Can present weeks or months postoperatively
- It resembles dementia
- Impairments seen in mood, memory, learning, language,
behaviour and motor function
- Treatment: correction of physiological parameters, good pain
relief and geriatrician involvement
20. References:
- Anesthesia for the elderly
- Anesthetic Considerations in the Geriatric
Population
- Anaesthesia in the Elderly
Questions:
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