Geriatric Anesthesia

Geriatric Anesthesia

As the 61 million adults of the Baby Boomer generation get older, policymakers will need to make social and financial decisions to avoid the feared “2030 problem” of depleted resources for the elderly.1 The main challenges of caring for older persons in 2030 will involve changes to payment and insurance systems for long-term care, advances in medicine and behavioral health, creation of community services for accessible care and alterations to cultural views of aging.1 Health professionals in particular will need to adjust their practices to accommodate an aging population, including developing competencies in geriatric care.2 Because older adults account for a disproportionately large amount of all surgical procedures performed in the United States,3 operating room clinicians are responsible for adapting their practices to fit patients’ ages. Older age is a risk factor for perioperative mortality, often mediated by preoperative comorbidity and invasiveness of the surgery.4 Thus, an anesthesiology practitioner must first evaluate the older patient’s physiological condition and then provide specialized perioperative care to prevent complications.4

Older age is correlated with many physiological changes that may affect anesthetic practice.5 Aging is associated with loss of function in all organ systems, with individual variability in onset and extent of bodily changes.4 Surgical stress can also exacerbate these functional conditions.4 In the central nervous system (CNS), for example, aging causes the brain and spinal cord to atrophy, which can lead to dementia, delirium and reduced reflexes or sensation.6 The cardiovascular system is also affected by aging, with older patients developing conditions such as hypertension, cardiovascular disease and inflammation of the blood vessels.7 Aging causes the respiratory system to lose function, causing issues such as impaired cough and airway clearance, lower oxygen levels and decreased responses to hypoxia.8 The hepatic system grows more vulnerable with older age, putting the patient at risk for acute liver injury and chronic liver diseases.9 Age-associated loss of kidney function includes lower glomerular filtration rate (GFR) and renal blood flow (RBF),10 which can be made even worse by anesthesia.11 Finally, the pharmacokinetics of drugs are altered in older populations, with volume of distribution reduced by about 20 percent, leading to higher peak concentrations.12 All of these age-related physiological changes can affect the administration of anesthetic drugs and the perioperative complications that may arise.13

Given the differences between younger and older adult patients, anesthesia providers should take extra precautions in the perioperative care of their aging patients. Anesthesia-related morbidity and mortality are high in the older population, often due to age-related disease.13 Thus, the anesthesia provider must adequately screen and prepare the patient before surgery.13 Kim et al. encourage specialized screening of physiologic and cognitive reserves in older patients, rather than using solely traditional cardiac-focused assessments.14 A satisfactory geriatric screening might include frailty characteristics, nutrition, cognitive/mental function and physical performance.13,14 After a preoperative assessment, the anesthesia provider is responsible for caring for the patient throughout surgery. The anesthesiology practitioner must make decisions on preferred anesthesia types, such as regional, general, sedation and monitored anesthesia.4 For example, Shen et al. found that etomidate was a better option than propofol in older patients undergoing gastroscopy, as it maintained hemodynamic stability and prevented adverse events.15 Given the slower drug distribution found in older patients, the clinician should also consider depth of sedation and anesthesia, as well as dosing.12 Postoperatively, the anesthesia provider should monitor the patient for indications of functional decline or loss of independence.16 Several authors have studied the risk of postoperative delirium in older patients, which may be common after gastrointestinal surgery17 and could be affected by level of sedation.18

The next decade will be marked by an increasingly aged population,1 and anesthesia provision will adapt to the times.13 The neurological, cardiovascular, respiratory, hepatic and renal systems change with age, as does drug metabolism.13 Anesthesiology practitioners need to be aware of these changes and make subsequent alterations to perioperative care. Future research and policy should approach new screening tools and standards of care for geriatric patients.

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2.         Williams BC, Warshaw G, Fabiny AR, et al. Medicine in the 21st Century: Recommended Essential Geriatrics Competencies for Internal Medicine and Family Medicine Residents. Journal of Graduate Medical Education. 2010;2(3):373–383.

3.         Neuman MD, Bosk CL. The redefinition of aging in American surgery. Milbank Quarterly. 2013;91(2):288–315.

4.         Barnett S. Anesthesia for the older adult. UpToDate. Web: Wolters Kluwer; 2019.

5.         Deiner S, Culley DJ. Anesthesia for the Older Patient. In: Burton JR, Lee AG, Potter JF, eds. Geriatrics for Specialists. Cham, Switzerland: Springer International Publishing; 2017:91–100.

6.         Aging changes in the nervous system. MedlinePlus. Bethesda, MD: National Institutes of Health; 2019.

7.         Paneni F, Diaz Cañestro C, Libby P, Lüscher TF, Camici GG. The Aging Cardiovascular System. Understanding It at the Cellular and Clinical Levels. 2017;69(15):1952–1967.

8.         Sharma G, Goodwin J. Effect of aging on respiratory system physiology and immunology. Clinical Interventions in Aging. 2006;1(3):253–260.

9.         Kim IH, Kisseleva T, Brenner DA. Aging and liver disease. Current Opinion in Gastroenterology. 2015;31(3):184–191.

10.       Weinstein JR, Anderson S. The aging kidney: Physiological changes. Advances in Chronic Kidney Disease. 2010;17(4):302–307.

11.       Burchardi H, Kaczmarczyk G. The effect of anaesthesia on renal function. European Journal of Anaesthesiology. 1994;11(3):163–168.

12.       Rivera R, M.D., Antognini Joseph F, M.D. Perioperative Drug Therapy in Elderly Patients. Anesthesiology: The Journal of the American Society of Anesthesiologists. 2009;110(5):1176–1181.

13.       Kotekar N, Shenkar A, Hegde AA. Anesthesia Issues in Geriatrics. In: Goudra BG, Duggan M, Chidambaran V, et al., eds. Anesthesiology: A Practical Approach. Cham: Springer International Publishing; 2018:795–825.

14.       Kim S, Brooks AK, Groban L. Preoperative assessment of the older surgical patient: Honing in on geriatric syndromes. Clinical Interventions in Aging. 2014;10:13–27.

15.       Shen X-C, Ao X, Cao Y, et al. Etomidate-remifentanil is more suitable for monitored anesthesia care during gastroscopy in older patients than propofol-remifentanil. Medical Science Monitor. 2015;21:1–8.

16.       Mohanty S, Rosenthal RA, Russell MM, Neuman MD, Ko CY, Esnaola NF. Optimal Perioperative Management of the Geriatric Patient: A Best Practices Guideline from the American College of Surgeons NSQIP and the American Geriatrics Society. Journal of the American College of Surgeons. 2016;222(5):930–947.

17.       Scholz AFM, Oldroyd C, McCarthy K, Quinn TJ, Hewitt J. Systematic review and meta-analysis of risk factors for postoperative delirium among older patients undergoing gastrointestinal surgery. BJS (British Journal of Surgery). 2016;103(2):e21–e28.

18.       Sieber FE, Neufeld KJ, Gottschalk A, et al. Effect of Depth of Sedation in Older Patients Undergoing Hip Fracture Repair on Postoperative Delirium: The STRIDE Randomized Clinical Trial. JAMA Surgery. 2018;153(11):987–995.