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Anesthesia and the
Elderly Patient
Sheila R Barnett, MD
Assistant Professor Anesthesiology
Harvard Medical School
Beth Israel Deaconess Medical Center
> 65y
Population
USA
>85 y
Surgery > 65 years

35% of surgeries in USA

16,000,000 surgeries per year
Surgery per 100 00
procedures
Frequency of 12 common
procedures
800
700
600
500
400
300
200
100
0
<15 y
15-44 y
45-64 y
>65 y
RISK & COMORBIDITIES
Aging involves physiological changes
AND
the pathophysiology of superimposed
disease
30 day Surgical Mortality
10
9
8
7
6
5
4
3
2
1
0
2nd Qtr
3rd Qtr
4th Qtr
27.4
90
20.4
38.6
34.6
31.6
46.9
45
43.9
All ages
60 -69y
70-79y
>80y
>90 y
30 Day Percent 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
Present later
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Review of colorectal surgery
Outcomes 65-74; 75-84; >85 years
34 194 patients
Oldest patients:
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Presented later
More co morbidities
Emergency more common
Survival lower
Lancet 2000; 356: 968
Preoperative conditions
100
80
%
60
40
20
0
DM
HT
CA
R
C
N
CA
D e na OP CN
CH
S
lD D
B
F
di
G
is
/
s
P
ea
ea
se
se TC
A
544 patients > 70 y. JAGS 2001 49:1080
344 high risk CEA patients, mean 72 y. NEJM 2004; 351:1493
Surgery Outcomes

> 70y non cardiac surgery ; prospective
544 patients – age 78y
21% adverse outcome
3.7 % died
Adverse outcomes:
Predictors: Emergency
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CVS 10%
ASA Class
CNS 8%
Pulmonary 5.5%
Tachycardia
Renal 2.5%
LOS: 9 vs 4 days (p<0.001) Preop : Functional status
CHF
Leung et al JAGS 2001 49:1080
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
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Not impacted by postoperative outcome
comorbid conditions, age and new hospitalizations
Manku & Leung Anesth Analg 2003;96:583 -94 (pts 1&2)
80 year old patients
26 648 > 80 y compared to 568 263 < 80 y
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30 day mortality all cases 8% vs. 3%, p<0.001
< 2% > 80 y for simple procedures
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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
General Risk Factors for
post operative mortality
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ASA 3 & 4
Major surgical procedures
Disease: Cardiac, pulmonary, DM, Liver
and renal impairment
Functional status < 1-4METS
Anemia & Low albumin
Bed ridden
Pathophysiology of Aging
Cardiovascular
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Peripheral
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Decrease in arterial elasticity – vascular
stiffening
Increase in BP
Increase peripheral vascular resistance
Ventricular
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Increased impedance - wall hypertrophy
decreased compliance
Resting CO unchanged
more atrial dependence
Cardiovascular Rate & Rhythm
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Conduction issues: Decline in pacemaker cells,
fatty infiltration, fibrosis
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Increase in atrial ectopy, sinus and ventricular
conduction defects
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Reduction in maximal HR – reduced response to
catecholamines
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Increased ischemic heart disease
Cardiovascular Autonomic Function
Dysautonomia of Aging
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Decline in beta receptor sensitivity
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HR responses impaired
Increased norepinephrine levels
Altered sympathovagal balance decreased HRV
Decreased baroreflex sensitivity
Heart Failure
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6-10% > 65 heart failure
80% admissions with heart failure are
>65 y
40 –50 % of patients with heart failure
have normal LVEF
Diastolic Dysfunction
251 patients / CAD
Age 72 y
Diastolic function : E/A & deceleration time
Diastolic
Function
Classification
Normal
Mild to Moderate
%
LVEF
37%
54%
57.9% 61.5%
Moderate
3.9%
Severe
1.7%
54.5%
54%
43%
Philip Anesth Analg 2003 ; 97 1214-21
MEN
HTN
Prevalence
WOMEN
Hypertension > 50% elderly
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Treatment usually > 140/90 mmHg
“High normal” 130-139/85-89 mmHg
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VA study –
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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
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
Increased Pulse Pressure
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Pulse pressure = SBP –DBP
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? Possible marker for vascular disease
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Low DBP also poor prognosis
Framingham Heart Study
1924 men & women Ages 50-79y
BP components & CHD risk
20 y f/u
CHD risk increased when
SBP > 120 and DBP
decreased
Franklin et al Circulation 1999; 100: 354
The ll/VI SEM
Aortic Sclerosis - is it really
benign?
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>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
Pulmonary Function and
Aging
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Thorax stiffens –
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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
Aspiration Risk
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Reduction pharyngeal sensation
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Reduction of maximal NIP
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Swallowing coordination may be
diminished
Central Nervous System
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Cortical grey matter attrition –
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starts in middle age
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Cerebral atrophy – disease vs. aging
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Increased intracranial CSF
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CBF and auto regulation largely maintained
CNS deficiencies
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Neurotransmitter deficiencies
Integration of neuronal circuits
Fluid intelligence
Spinal cord demyelination
Decreased spinal reflexes
Peripheral nervous system
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Fibrosis in peripheral nerves
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Less myelinated fibers
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Slower nerve conduction
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Diminished muscle mass
CNS & Drugs
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Pharmacodynamic
MAC
Altered respiratory drive & drugs
Spinal drugs
Epidural spread sensitivity
Cognitive Dysfunction
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Post operative delirium
Cognitive dysfunction:non-cardiac
surgery
Post cardiac surgery
Post-operative delirium
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Incidence 10-15% in
>65y
Increased mortality
Longer hospital stay
Numerous risk factors:
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Advanced age
Dementia, Depression
Anemia
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Alcohol and drug withdrawal
Metabolic derangement
Acute MI
Infection
Emergency surgery
Delirium costs!
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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
Postoperative Cognitive
Dysfunction
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Early
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1218 patients >60 years
Early 7 days 26%
Late 3 months 9.9% (controls 2.8%)
Increasing Age
Duration anesthesia
Low education
Second operation
Infections
Respiratory Complications
Late
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Age only
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Moller et al Lancet 1998
Is it the Anesthetic?
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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
Confusion – what can you do?
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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
Mild Cognitive Impairment
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“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
Vascular patients
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Longitudinal study – 11 years
4141 men & 1681 women
Cognitive testing
Poor cognitive function Independent of
age or SE class
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Angina p 0.001
MI p 0.02
Claudication p.004
Singh-Manoux JAGS 2003; 51:1445
Should we do more?
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Informed Consent ?
Hospitalization “unmask” marginal cognitive
function
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Dementia prevalent
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Postoperative rehabilitation plans
Cognitive Preoperative Assessments?
Renal Function
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Progressive decrease in Renal Blood flow
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Renal tissue atrophy - primarily cortical
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30% reduction in nephrons age by middle age
Sclerosis reaming nephrons
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Glomerular filtration rate declines
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Serum creatinine misleading –
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‘occult’ renal insufficiency
Fluid homeostasis
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Sodium conservation impaired
Urine concentrating ability reduced
Thirst diminished
Post operative Acute Renal Failure >50%
mortality in very elderly patients
Body Compartments
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Decline in total body water
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intracellular water
plasma volume maintained
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Less lean tissue & skeletal muscle mass
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Increase proportion of fat
Hepatic
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Decrease in hepatic mass
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Decrease in hepatic clearance
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Less albumin
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Qualitative change in protein binding
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Alpha-1-glycoprotein increases
Drug considerations
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water soluble drugs
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prolonged half life of lipophilic drugs
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decreased hepatic metabolism& renal
clearance
increased target organ sensitivity
Risk – What Dose?
Summary pathophysiology
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Steady decline in organ function
Unpredictable reserve function
Increased comorbidity
Reserve Function Diminished
Risk Reduction
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Beta Blockade
Comprehensive assessments
Less invasive surgery
? Regional
Beta Blockade & Risk
Reduction
Mangano NEJM 1996;335:1713
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100/200 patients received Atenolol
preop and for 7 days
Atenolol group improved survival 6
months & up to 2 y. Diabetes major
risk
Wallace Anesth 1998;88:7
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Atenolol reduced postoperative ischemia
by 30- 50%
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High risk vascular patients with positive
dobutamine echocardiograhpy.
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Mean age 68y
173/ 846 positive echos
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59 bisoprolol
61 excluded on Beta blockers /wma
53 standard care (SC)
Bisoprolol vs SC death or non fatal MI:
2 (3.4%) vs 18 (34%)
Poldermans NEJM 1999;341:1789
Beta blockers continued …
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> 600 000 patients undergoing non
cardiac surgery
18% received perioperative beta
blockade
Reduction in death for those with a
Cardiac Risk Index Score of 2-4
But possible increased risk of death for
those with Cardiac Risk Index of 0 or 1
Lindenauer et al NEJM 2005; 353:349
Beta Blocker Prescription
after AMI by Age
45,370 patients
eligible for beta
blockade
60
50
40
30
20
10
0
65
-
70
75
80
85
90
>9
5
-7
69
79
84
89
94
4
Vitagliano et al. JAGS 2004: 52:495
Beta Blockers & the Frail
60
Percentage Beta
blockers
50
40
30
20
10
0
I
II
III
IV
Frailty Stage
Vitagliano et al. JAGS 2004: 52:495
Comprehensive Geriatric
Assessments (CGA)
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120 patients >60 y
CGA
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ADLs, IADLs (Barhtel Index) , comorbidity,
nutrition, MMSE
All undergoing thoracic surgery
17% post op complications
Predictors –
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Low Barthel Index
Surgery >300 mins
Dementia – low MMSE
Fukuse Chest 2005; 127:886
Intervention Program to
Reduce Delirium
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400 patients > 70 y
Admitted to Intervention Ward
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Assessment, prevention treatment education
Assessment day 1,3,7
Delirious patients in the Intervention ward
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Shorter duration: by day 7 30% vs 60% (p 0.001 )
Shorter LOS: 9 vs 13 days (p 0.001)
Reduced mortality: 2 vs. 9 patients died (p 0.03)
Lundstrom et al JAGS 2005:53:622
Less invasive surgery ?
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CEA
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Yadav et al NEJM 2004; 351:1493
344 high risk patients average 72 y
Stent vs. open
Results showed stent as good – possible
reduction in death at 1 year and at least
as good or less adverse events
Endovascular AAA
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1 year perioperative survival advantage vs.
open
Blankenstein et al NEJM 2005; 352:2398
Spinal or Epidural vs. General
Anesthesia
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Long a source of controversy
Expert opinion suggesting no significant
difference in major complications or mortality
Meta-analysis of 141 randomized trials
Total of 9559 patients
Studied neuraxial blockade (either spinal or
epidural anesthesia) vs. general anesthesia
BMJ 2000;321:1
Rodgers et al BMJ 2000; 321:1-12
Meta-Analysis of Neuraxial Blockade
vs. General Anesthesia
Rodgers et al BMJ 2000; 321:1-12
Perioperative event
Death
DVT
Pulmonary embolism
Pneumonia
Respiratory depression
Myocardial infarction
Odds reduction
for neuraxial
blockade
30%
44%
55%
39%
59%
33%
Fractures too…
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Meta analysis
15 randomized trials 2162 patients
In Spinal:
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Reduction in 1 month mortality (6% vs
9%)
Reduction in DVT
Future – epidural vs LMWH and other
anticoagulant strategies
Urwin et al Br J Anesth 2000; 84(4) 450-455
Cataracts
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Low risk
High volume
High comorbidity
Do you ever wonder why we
are in the room?
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1999 Survey in USA
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Rosenfeld in 1999
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1006 patients
33% needed an intervention during surgery
No predictive factors
International Studies
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45% Ophthalmologists using topical
78% anesthesiologist present
But low topical rate
Reeves survey
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‘net preference’ for anesthesiologists
Routine Preoperative Testing before Cataract
Surgery
18 189 Cataract patients
Routine Testing
9408 Patients
Routine Testing
No Testing
9411 Patients
No Testing
Preoperative Medical Assessment
EKG; CBC; Lytes, BUN,
Creat & Gluc
No tests unless new or
worsening condition
Both groups intra and postoperative medical
events 3.1/ 1000 operations
Stein et al; NEJM 2000; 342: 168
“Routine medical testing before cataract
surgery does not measurably increase the
safety of the surgery”
But…
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Preoperative evaluation done in ALL
patients and ALL patients had opportunity
to have testing
Conclusion
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Testing should directed by history and
physical performed prior to surgery
The Hip Fracture
A Morbid Event
Is the hip fracture the sentinel event
marking deterioration ?
Hip fractures
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300 000 hospitalizations
1 year mortality 25% - reduction life
expectancy
Attributable cost of fracture $81 300
Disability significant M & M
US in 1997 > $20 Billion

Braithewaite JAGS 2003; 51: 364
Hip fractures, old people and the
inevitable …..
Hip fractures have high perioperative
mortality 10 -25%
Why?
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300 unselected hip fractures
All received similar multimodal treatment
Anesthesia epidural / strict protocol
Well defined rehabilitation
Foss & Kehlet 2005; Br J Anaesth 94; 24-9
Why did they die?
Foss & Kehlet 2005; Br J Anaesth 94; 24-9
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30 day mortality =13% ; >30 days 7 more died
Combined mortality=16%
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Analysis of 47 deaths
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28% (13) unavoidable: terminal cancer, refused care
15% (7) probably unavoidable
34% (16) potentially avoidable; active care curtailed
23% (11) Maximum care; ? avoidable
Miscellaneous
Sensory Changes
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Decreased visual acuity & dark adaptation
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Attrition of taste buds
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Diminished thirst sensation
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Compromised joint perception
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Diminished fine control of skeletal muscles
DISABILITIES COMMON
> 80y
Polypharmacy
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Adverse drug events 3 -10% admissions
common
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Elderly on multiple medications
30% prescriptions & 40% of OTC drugs
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Drugs and herbs
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eg Ephedra alkaloids -ma huang
Adverse Events : HTN, palpitations,
strokes, seizures
ETOH & Elderly
Alcohol and Drug prescription problems
affect 17% of older Americans
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Increase sensitivity & decrease in
tolerance
Decrease lean body mass & TBW = higher
concentration
Decrease in alcohol dehydrogenase may
slow metabolism
Social Issues
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Increase in disability
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Lack of a spouse
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Cognitive and sensory problem
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Scheduling - a family commitment
Challenges & Elderly
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heterogeneous population
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unpredictable organ reserve
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disease burden

atypical disease presentation

emergent procedures

minor complications can rapidly escalate
Geriatric Graphs
Disease or badness
Age years
Function
Age years
Future ?

Cognitive Preoperative assessment

Functional outcomes
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Perioperative interventions