Anesthetic management of elderly patients requires special considerations. The elderly population is growing rapidly. Preoperative testing may not be needed for low or intermediate risk surgery if the patient is followed by their primary care physician and has no concerning findings on history and physical. Anesthetic drugs have longer durations of action in the elderly and some require lower doses for induction to avoid hypotension. Emergence from anesthesia takes longer in the elderly and regional anesthesia may be preferable to general anesthesia when possible. Careful titration of anesthetic drugs is important due to age-related changes in pharmacokinetics and pharmacodynamics.

1. Anesthetic Management of
the Elderly Patient
Raymond C. Roy, PhD, MD
Professor & Chair of Anesthesiology
Wake Forest University Health Sciences
Winston-Salem, NC, USA 27157-1009
http://www.wfubmc.edu/anesthesia
Education: Annual Meeting – American Society of Anesthesiologists

2. Hayflick’s View of Aging
“Because modern humans, unlike feral
animals, have learned how to escape
death long after reproductive success, we
have revealed a process that,
teleologically, was never intended for us
to experience.”

3. # Older Americans
2000 2030
> 65 yrs 12.4% 19.6%
35 mil 71 mil
> 80 yrs 9.3 mil 19.5 mil

5. The Oldest…..
• MAN 120 yrs
• WOMAN 122
– Guinness Book of Records
• GENERAL ANESTHETIC 113
– Br J Anaesth 2000; 84:260

6. Life Expectancy at birth
USA - 1997
WOMEN Caucasian 79.9 yrs
African-American 74.7
MEN Caucasian 74.3
African-American 67.2

7. Life Expectancy, Life Span,
& Maximum Length of Life
• Maximum Length of Life > 120 yrs
• Life Span 85-100
– Natural death (no trauma or disease)
• Life Expectancy (USA) 67-80
– Premature death (trauma, disease)

8. Oldest Surgical Patient?
Oliver. Br J Anaesth 2000; 84:260
• Woman, 113 yrs, femoral fracture
• General anesthesia
• CVP, no arterial-line
• Extubation in ICU after 5h
• Hospital discharge POD 23

9. # Anesthetics per 100 Population?
Clergue. Anesthesiology 1999; 91:1509 (France)
Ages (yrs) Men Women
35 – 44 8.9 13.2
55 - 64 17.7 14.6
75 - 84 30.2 23.6

10. Vascular Surgery – Mortality vs Age
Fleisher. Anesth Analg 1999; 89:849
25%
20%
15%
aortic
10% infrainquinal
5%
0%
<65 66-70 71-75 76-80 81-85 >85 yrs

11. Perioperative Complication
Rates in Medicare Patients
• Intermediate Risk Surgery - 42%
– Silber, Anesthesiology 2000; 93:152
– 217,440 general & orthopedic surgery
• Low Risk Surgery - 3%
– Schein, N Engl J Med 2000; 342:168
– 18,901 cataract surgery

12. Age & Perioperative Outcome
• With advancing age
– More surgery
– Morbidity increases
– Mortality increases
• Cause - disease vs age ?
– Disease > age when < 85 yrs
– Age may = disease when > 85 yrs
– Increase ASA PS when > 85 yrs

13. Preoperative Considerations
• Preoperative Assessment
– No routine preoperative testing
– Statin myopathic syndromes
– Diastolic dysfunction
• Diabetes Mellitus
– Tighter glucose control with insulin
– Stop oral hypoglycemic agents

14. Why Obtain Preoperative Tests?
• Screening – NO with one exception
– Urinalysis if hip surgery or acutely ill
– Cook & Rooke, Anesth Analg 2003; 96:1823
• Treatment effectiveness - YES
• Baseline – MAYBE, but overused
• Risk Assessment - YES

15. Value of Preoperative Testing
Before Low Risk Surgery
Schein. N Engl J Med 2000; 342:168
Rate/100 Untested Tested
Medical Event: Intraop 1.87 1.94
Postop .92 .94
Unplanned Hospitalization .34 .29
Death .02 .01
Total 3.13 3.13

16. Value of Preoperative Testing
Before Low Risk Surgery
Schein. N Engl J Med 2000; 342:168
“Tests should be ordered only when the
history or a finding on a physical
examination would have indicated the
need for the test even if surgery had
not been planned.”

17. Intermediate Risk Noncardiac
Surgery (Mortality > 1%, < 5%)
CAROTID
HEAD & NECK
INTRAPERITONEAL
INTRATHORACIC
ORTHOPEDIC
PROSTATE

18. Preoperative Tests - Prevalence of
Abnormal Results
544 consecutive intermediate risk non-cardiac surgical
patients > 69 yrs - Dzankic. Anesth Analg 2001; 93:301
Creatinine > 1.5 mg/dL 12%
Hemoglobin < 10 mg/dL 10%
Glucose > 200 mg/dL 7%
K+ < 3.5 mEq/L 5%
K+ > 5.0 mEq/L 4%
Platelets < 115,000/ml 2%

19. Outcomes of Patients with No
Laboratory Assessment for
Intermediate Risk Surgery
N = 1,044
Narr. Mayo Clin Proc 1997; 72:505
“Patients … assessed by history and
physical examination … safely
undergo … operation with tests drawn
only as indicated intraoperatively and
postoperatively.”

20. Is ROUTINE Preoperative
Testing Indicated?
NO (my opinion), IF
– FOLLOWED BY PRIMARY CARE MD
– RELIABLE SYSTEM TO OBTAIN H & P
– NO “RED FLAGS” IN H & P
– MODERATE FUNCTIONAL STATUS +
INTERMEDIATE RISK SURGERY
OR
POOR BUT STABLE FUNCTIONAL STATUS +
LOW RISK SURGERY

21. No Non-invasive or Invasive
Cardiac Testing for Intermediate
Risk Surgery
MODERATE FUNCTIONAL CAPACITY +
INTERMEDIATE CLINICAL PREDICTORS
OR
POOR FUNCTIONAL CAPACITY + MINOR
CLINICAL PREDICTORS
J Am Coll Cardiol 1996; 27:910

22. INTERMEDIATE
CLINICAL PREDICTORS
MILD STABLE ANGINA
PRIOR MI
COMPENSATED CHF
PRIOR CHF
DIABETES MELLITUS

23. FUNCTIONAL CAPACITY
MET= metabolic equivalent O2
consumption of 70 kg, 40 yr old
man in resting state
> 7 METs - excellent
4-7 METs - moderate
< 4 METs - poor
– J Am Coll Cardiol 1996; 27:910-48

24. Estimated Energy Requirements
for Activities of Daily Living - 1
1 MET -------------------------> 4 METs
– eat, dress, use toilet
– walk indoors around house
– walk 1-2 blocks on level ground
– light house work

25. Estimated Energy Requirements
for Activities of Daily Living - 2
4 METs -------------------> 10 METs
– climb flight of stairs, walk up a hill
– walk briskly on level ground
– run a short distance
– do heavy house work
– golf, bowling, dancing, doubles tennis

26. Most Difficult ROUTINE
Preoperative Tests to Justify
• Chest X-ray
• PT and aPTT (if no heparin or warfarin)
• Liver Function Tests

27. 4 Statin Myopathic Syndromes
Thompson. JAMA 2003; 289:1681
• STATIN MYOPATHY
– Any muscle complaint with onset
coincident with start of statin therapy
• MYALGIA with normal CK
• MYOSITIS with elevated CK
• RHABDOMYOLYSIS

28. % of Older Patients with
Diastolic Dysfunction
60
50
40
30 Mild
Moderat e
20
Severe
10
0
45-54 55-64 65-74 75 or
great er

29. Diabetes Mellitus – 8.7% of
Elderly
• Ischemic heart disease
• Problems with all oral hypoglycemic agents
• More infections – pulmonary, wound
• Decreased pulmonary function
• Decreased response to hypoxia
• Prolonged response to vecuronium

30. Problems with Oral
Hypoglycemic Agents
Gu. Anesthesiology 2003; 98:1359
• Sulfonylureas – myocardial ischemia
– Interfere with K-ATP channels
– Prevent ischemic preconditioning
– Eliminate ECG benefit of warm-up
– Eliminate functional benefit of warm-up
– Worsen dipyridamole-induced ischemia
• Metformin – lactic acidosis

31. Diabetes Mellitus – Tight
Control of Glucose
Gu. Anesthesiology 2003; 98:1359
• Insulin infusions to maintain glucose:
– 80-150 mg/dl intraoperatively
– 80-110 mg/dl postoperatively
• Reduce ICU mortality by 40%
• Improve outcome from acute MI
• Decrease infections

32. Beta-adrenergic Blocking
Agents – Perioperative
Administration
• Reduces myocardial ischemia
• Reduces myocardial infarction
• Secondary Observations
– Zaugg. Anesthesiology 1999; 91:1674
– Decrease anesthetic administration
– Enable faster emergence
– Decrease post-op analgesic requirement

33. Perioperative Myocardial
Ischemia
Wallace. Anesthesiology 1998; 88:7
MYOCARDIAL ATENOLOL PLACEBO
ISCHEMIA
(N = 99) (N = 101)
POD 0 - 2 17 34*
* p = 0.008
POD 0 - 7 24 39**
**p = 0.029

34. Perioperative Beta-Blockade -
Therapeutic Target
Auerbach. JAMA 2002; 287:1435
• HEART RATE 55 – 65 bpm
• SYSTOLIC >100 mm Hg
• Before, during, and after surgery

35. Actual Practice versus Evidenced-
based Beta-blockade – “Wrong”
Answers from ABA Oral Examinees
• DID NOT ADD IN PREOP CLINIC
• USED HR 80 AS TARGET INTRAOP
• DID NOT ORDER POSTOP (7 days)
• ASSUMED ESMOLOL-BOLUS = LONG-
ACTING PRE-, INTRA-, POSTOP
(REACTIVE vs PROPHYLACTIC)

36. General Anesthesia
• Anesthetic depth
• Neuromuscular blocking agents
• Diastolic pressure
• Transfusion trigger
• Regional vs general anesthesia

37. MAC & Age
Nickalls. Br J Anaesth 2003; 91:170
9
8
7
6
5 1 yr
4 40 yr
3 80 yr
2
1
0
I soflurane Sevoflurane Desflurane

38. Nitrous Oxide MAC & Age
Nickalls. Br J Anaesth 2003; 91:170
140
120
100
80 1 yr
40 yr
60
80 yr
40
20
0
Nit rous Ox ide

39. End-tidal Isoflurane to Provide
MAC with N2O in 80 Year Olds
Nickalls. Br J Anaesth 2003; 91:170
1
0.8
0.6 0% N2O
50% N2O
0.4
67% N2O
0.2
0
I sof lurane

40. Most of Us Overdose Elderly
• Gas monitors
– Assume patient is 40 yrs old
– Do not know what other drugs given
– Do not know opioids & epidurals lower MAC
– Underestimate brain concentration on emergence
• BIS Index 55-60 with beta-blockers better than
BIS Index 35-45

41. End-tidal Concentrations Under-
estimate Brain Concentrations
During Emergence from Isoflurane
Lockhart. Anesthesiology 1991; 74:575
0.7
0.6
0.5
0.4 End-t idal conc
rat io
0.3 Cerebral conc rat io
0.2
0.1
0
0-6 13-18 25-30 m in

42. PROPOFOL INDUCTIONS IN 25 –
81 YR-OLDS
Schnider. Anesthesiology 1999; 90:1502
• Propofol: 2 mg/kg < 65 yrs; 1 mg/kg > 65 yrs
• Injection time 13-24 s
• Loss of consciousness
– Young = old = 40 s
• Return of consciousness
– 30 yrs – 5 min, 75 yrs – 10 min

43. PROPOFOL INDUCTIONS 20
– 84 YRS
Kazama. Anesthesiology 1999; 90:1517
HALF-TIME FOR NADIR IN BP
20 – 29 yrs 5.7 min
70 – 85 yrs 10.2 min

44. PROPOFOL INDUCTIONS >
65 YRS
Habib. Br J Anaesth 2002; 88:430
Glycopyrrolate, propofol 1 mg/kg, and
either alfentanil 10 μg/kg or remifentanil
0.5 μg/kg + 0.1 μg/kg/min
SBP: < 100 mmHg 50%, < 80 mmHg 8%

45. RECOMMENDED PROPOFOL DOSE
FOR INDUCTION IF > 65 yrs old
IF BOLUS (< 30 s)
No concurrent drugs 1.0-1.5 mg/kg
Concurrent drugs 0.5-1.0 mg/kg
HYPOTENSION
Continues for 10 min after injection
Fentanyl peak 6-8 min, midazolam peak 5 min
PREFER SLOWER INJECTION (1 min)
Less hypotension if slow with < 1.0 mg/kg

46. Elderly Take Longer to Emerge
Than Younger Patients
• Lower MACawake and higher pain threshold
• Hypothermia more likely
• Emergence hypertension treated as light anesthesia
• Reluctance to turn off vaporizer
• Longer durations of action for drugs in elderly
• Relative drug overdoses
• Synergistic drug interactions

47. Neuromuscular Blocking Agents
in the Elderly - 1
• Same initial dose as in younger
• Longer onset times with:
– Advanced age
– Vecuronium vs rocuronium
• Tullock. Anesth Analg 1990; 70:86
– Esmolol
• Szmuk. Anesth Analg 2000; 90:1217]

48. Onset Time (sec) Increases with
Advancing Age
Koscielniak-Nelson. Anesthesiology 1993; 79:229
300
250
200
succinylcholine 1
150 m g/ kg
vecuronium 0.1
100 m g/ kg
50
0
3-10 yrs 20-40 60-80

49. Neuromuscular Blocking Agents
in the Elderly - 2
• Longer duration (except cisatracurium)
– Advanced age
– Intraoperative hypothermia (34.7o C)
– Diabetes mellitus (8.7% of elderly)
– Obesity – dosing mg/kg

50. Obesity in Older Men
% with BMI > 29.2
Flegal. JAMA 2002; 288:1723
40
35
30
25
20 1990
15 2000
10
5
0
60-69 70-79 80+ yrs

51. Obesity in Older Women
% with BMI > 29.2
Flegal. JAMA 2002; 288:1723
45
40
35
30
25 1990
20
2000
15
10
5
0
60-69 70-79 80+ yrs

52. Times to Reappearance of T1, T2, T3,
& T4 after Vecuronium 0.1 mg/kg in
Patients with Diabetes Mellitus
Saito. Br J Anaesth 2003; 90:480
70
60
50
40
No DM
30 DM
20
10
0
T1 T2 T3 T4

53. Effect of Hypothermia on Time-to-
25%-Recovery from Vecuronium 0.1
mg/kg
Caldwell. Anesthesiology 2000; 92: 84
70
60
50
40
30 Time (min)
20
10
0
34 35 36 37 38 C

54. Rocuronium > Vecuronium >
Pancuronium (My Practice)
Fastest onset
Shortest duration
Least inter-patient variability
Easiest to reverse
Shortest PACU length of stay
Fewest post-op pulmonary complications
[Cisatracurium > rocuronium if renal insufficiency]

55. Transfusion Trigger for Elderly
Hgb 10 g/dl or Hct 0.30
• Ischemic Heart Disease
– Especially if reversible ischemia, unstable
angina, recent infarction or dysfunction
• Pulmonary Disease
– Intra-thoracic or intra-abdominal surgery
• Leukocyte-reduced
• Walsh, McClelland, Br J Anaesth 2003; 719

56. Minimum Diastolic Pressure
Pauca Abstract ASA 2003
• When treating systolic pressure (SP), pay
attention to diastolic pressure (DP)
• To maintain coronary perfusion, keep
– DP at least 2/3rd SP
– DP greater than Pulse Pressure
– DP at least 60 mmHg

57. Regional vs General
Anesthesia – Mortality &
Morbidity
REGIONAL = GENERAL
• BP, HR tightly controlled in studies
• More interventions to control BP, HR in
general anesthesia group
REGIONAL < GENERAL
• “Real world” , BP, HR not tightly controlled
• Included combined regional-general in
regional group
• Rogers et al. Br Med J 2000;321:1493

58. Postoperative Considerations
• Postoperative Analgesia
• Postoperative Delirium

59. Postoperative Titration of
Intravenous Morphine in Elderly
Patients
Abrun. Anesthesiology 2002; 96:17
• Bolus q 5 min to VAS = 30 (max 100)
– 2 mg if <60 kg; 3 mg if > 60 kg
• Total mg/kg dose: young = old
– Young (< 70, mean 45) vs Old (> 70, mean 76)
• Morbidity – young = old
– adverse opioid effects, sedation, stopped
titrations

60. Age is not an Impediment to
Effective Use of PCA
Gagliese. Anesthesiology 2000; 93:601
• Initial Dose for Pain Relief:
– young = old
• Total Dose:
– old < young

61. Postoperative Delirium in 5-50%
That Appears on POD’s 1-3
Cook. Anesth Analg 2003; 96:1823
• Cellular proteins altered by potent inhaled agents
• Central cholinergic insufficiency, Microemboli
• Preexisting subclinical dementia, Hypoxia
• Fever, Infection (UTI, sinusitis, pneumonia)
• Electrolyte abnormalities, Anemia, Pain
• Sleep deprivation, Unfamiliar environment

62. Ten Ways to Improve
Anesthesia in Older Patients
1. H & P > Pre-op Testing > CXR, PT, PTT
2. Beta-blockers pre-. intra-, post-op
3. Timely antibiotic administration
4. Lower doses of inhaled & iv agents
5. Rocuronium or cisatracurium

63. Ten Ways to Improve
Anesthesia in Older Patients
6. Higher FIO2 intra-, post-op
7. Transfusion trigger – Hct .30
8. Diastolic pressure 60 mmHg
9. Blood glucose - periop 80-150 mg/dl
10. Reduce post-op opioid requirements