Practical Management of Anaesthesia in the Elderly

Abstract

The elderly population is rapidly growing and particularly diverse. Ageing leads to reduced organ function and a decline in physiologic reserve. Elderly patients are characterised by great inter-individual variability in physiological function with a high prevalence of chronic disease. In general, older patients have a higher risk of postoperative adverse outcomes, and frailty is a very important risk factor. This review article aims to provide a practical guide to anaesthetic management of the elderly surgical patient. To optimise care, clinicians should be familiar with the typical physiologic changes related to ageing and the implications for anaesthetic management. All anaesthetic techniques, methods and agents can be applied, if tailored to the patient's physiologic and pathologic changes. The elderly are more sensitive to anaesthetics, meaning that desired sedative and analgesic effects are reached at lower doses compared with younger patients, and the haemodynamic depressing side effects of anaesthetics are often more pronounced. To reduce the risk of circulatory collapse, the clinician should carefully titrate anaesthetics and await the response with patience. The dose of neuromuscular blocking agents should rarely be reduced for intubation, but the duration of action of neuromuscular blocking agents is often prolonged and difficult to predict. Perioperative neuromuscular monitoring is therefore strongly recommended. In the postoperative period, prevention of avoidable morbidity and functional decline is crucial; comprehensive multidisciplinary care and multimodal interventions may facilitate earlier recovery and decrease the risk of complications.

Frailty and anesthesia – risks during and post-surgery

“…Furthermore, aging reduces renal mass, the speed of renal excretion of drugs, and patients have increased sensitivity to drugs with potential for renal toxicity. 30 Frailty is associated with a reduction in estimated glomerular filtration rate. In pre-dialysis patients with chronic kidney disease, frailty conferred a negative prognostic survival factor.…”

“… 32 Furthermore, frailty is associated with cardiac autonomic dysfunction, 33 the impact of which can result in blood pressure lability, particularly profound, prolonged hypotension in response to the administration of anesthesia, particularly in the setting of hypovolemia which is often encountered in the perioperative period. 29 , 30 …”

<p>Risk Factors of Pulmonary Complications After Minimally Invasive Surgery for Elderly Patients with Vertebral Compression Fractures</p>

“…6,[28][29][30][31] Besides, hypertension and cardiovascular diseases were also identified as the risk factors of complication after spinal surgery. 8,[32][33][34][35] In the present study, we retrospectively evaluated elderly patients (≥ 65 years) diagnosed with VCFs who underwent PVP or PKP surgery. The incidence of pulmonary complications after surgery reached 11.59% in 233 enrolled patients.…”

Anesthetic management of geriatric patients

“…The dose of neuromuscular blocking agents (NMBAs) should hardly be reduced in the elderly for intubation, but their duration of action is often prolonged and difficult to predict along with age-induced changes in pharmacokinetics of long and intermediate-acting NMBAs (especially, aminosteriods including rocuronium and vecuronium), which may cause postoperative residual neuromuscular blockade and associated complications. Therefore, perioperative neuromuscular monitoring including a train-offour monitoring is strongly recommended [97] .…”

“…For depth of anesthesia monitoring, processed electroencephalogram (EEG) neuromonitoring including a bispectral index or entropy monitor is recommended to avoid excessive depth of anesthesia, thereby preventing the development of POD [95,96] or POCD [100] in elderly patients. Lastly, perioperative neuromuscular monitoring is strongly recommended to keep the proper degree of neuromuscular blockade and its safe reversal [97,101].…”