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Anesthesia and the Elderly Patient

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. RISK & COMORBIDITIES.

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Anesthesia and the Elderly Patient

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  1. Anesthesia and the Elderly Patient Sheila R Barnett, MD Assistant Professor Anesthesiology Harvard Medical School Beth Israel Deaconess Medical Center

  2. > 65y Population USA >85 y

  3. Surgery > 65 years • 35% of surgeries in USA • 16,000,000 surgeries per year

  4. RISK & COMORBIDITIES Aging involves physiological changes AND the pathophysiology of superimposed disease

  5. 30 day Surgical 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

  6. Present later • Review of colorectal surgery • Outcomes 65-74; 75-84; >85 years • 34 194 patients • Oldest patients: • Presented later • More co morbidities • Emergency more common • Survival lower Lancet 2000; 356: 968

  7. Preoperative conditions % 544 patients > 70 y. JAGS 2001 49:1080 344 high risk CEA patients, mean 72 y. NEJM 2004; 351:1493

  8. Surgery Outcomes > 70y non cardiac surgery ; prospective 544 patients – age 78y 21% adverse outcome 3.7 % died • Adverse outcomes: • CVS 10% • CNS 8% • Pulmonary 5.5% • Renal 2.5% • LOS: 9 vs 4 days (p<0.001) Predictors: Emergency ASA Class Tachycardia Preop : Functional status CHF Leung et al JAGS 2001 49:1080

  9. 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 • Not impacted by postoperative outcome • comorbid conditions, age and new hospitalizations Manku & Leung Anesth Analg 2003;96:583 -94 (pts 1&2)

  10. 80 year old patients 26 648 > 80 y compared to 568 263 < 80 y • 30 day mortality all cases 8% vs. 3%, p<0.001 • < 2% > 80 y for simple procedures • 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

  11. General Risk Factors for post operative mortality • ASA 3 & 4 • Major surgical procedures • Disease: Cardiac, pulmonary, DM, Liver and renal impairment • Functional status < 1-4METS • Anemia & Low albumin • Bed ridden

  12. Pathophysiology of Aging

  13. Cardiovascular • Peripheral • Decrease in arterial elasticity – vascular stiffening • Increase in BP • Increase peripheral vascular resistance • Ventricular • Increased impedance - wall hypertrophy • decreased compliance • Resting CO unchanged • more atrial dependence

  14. Cardiovascular Rate & Rhythm • Conduction issues: Decline in pacemaker cells, fatty infiltration, fibrosis • Increase in atrial ectopy, sinus and ventricular conduction defects • Reduction in maximal HR – reduced response to catecholamines • Increased ischemic heart disease

  15. Cardiovascular Autonomic Function Dysautonomia of Aging • Decline in beta receptor sensitivity • HR responses impaired • Increased norepinephrine levels • Altered sympathovagal balance - decreased HRV • Decreased baroreflex sensitivity

  16. Heart Failure • 6-10% > 65 heart failure • 80% admissions with heart failure are >65 y • 40 –50 % of patients with heart failure have normal LVEF

  17. Diastolic Dysfunction 251 patients / CAD Age 72 y Diastolic function : E/A & deceleration time 61.5% Philip Anesth Analg 2003 ; 97 1214-21

  18. HTN Prevalence MEN WOMEN

  19. Hypertension > 50% elderly • Treatment usually > 140/90 mmHg • “High normal” 130-139/85-89 mmHg • VA study – 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

  20. 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

  21. Increased Pulse Pressure • Pulse pressure = SBP –DBP • ? Possible marker for vascular disease • Low DBP also poor prognosis

  22. Framingham Heart Study1924 men & women Ages 50-79yBP components & CHD risk 20 y f/u CHD risk increased when SBP > 120 and DBP decreased Franklin et al Circulation 1999; 100: 354

  23. The ll/VI SEM

  24. Aortic Sclerosis - is it really benign? • >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

  25. Pulmonary Function and Aging • Thorax stiffens – • 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

  26. Aspiration Risk • Reduction pharyngeal sensation • Reduction of maximal NIP • Swallowing coordination may be diminished

  27. Central Nervous System • Cortical grey matter attrition – • starts in middle age • Cerebral atrophy – disease vs. aging • Increased intracranial CSF • CBF and auto regulation largely maintained

  28. CNS deficiencies • Neurotransmitter deficiencies • Integration of neuronal circuits • Fluid intelligence • Spinal cord demyelination • Decreased spinal reflexes

  29. Peripheral nervous system • Fibrosis in peripheral nerves • Less myelinated fibers • Slower nerve conduction • Diminished muscle mass

  30. CNS & Drugs • Pharmacodynamic • MAC • Altered respiratory drive & drugs • Spinal drugs • Epidural spread sensitivity

  31. Cognitive Dysfunction • Post operative delirium • Cognitive dysfunction:non-cardiac surgery • Post cardiac surgery

  32. Incidence 10-15% in >65y Increased mortality Longer hospital stay Numerous risk factors: Advanced age Dementia, Depression Anemia Alcohol and drug withdrawal Metabolic derangement Acute MI Infection Emergency surgery Post-operative delirium

  33. Delirium costs! • 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

  34. Postoperative Cognitive Dysfunction • 1218 patients >60 years • Early 7 days 26% • Late 3 months 9.9% (controls 2.8%) • Early • Increasing Age • Duration anesthesia • Low education • Second operation • Infections • Respiratory Complications • Late • Age only • Moller et al Lancet 1998

  35. Is it the Anesthetic? • 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

  36. Confusion – what can you do? • 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

  37. Mild Cognitive Impairment • “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

  38. Vascular patients • Longitudinal study – 11 years • 4141 men & 1681 women • Cognitive testing • Poor cognitive function Independent of age or SE class • Angina p 0.001 • MI p 0.02 • Claudication p.004 Singh-Manoux JAGS 2003; 51:1445

  39. Should we do more? • Informed Consent ? • Hospitalization “unmask” marginal cognitive function • Dementia prevalent • Postoperative rehabilitation plans Cognitive Preoperative Assessments?

  40. Renal Function • Progressive decrease in Renal Blood flow • Renal tissue atrophy - primarily cortical • 30% reduction in nephrons age by middle age • Sclerosis reaming nephrons • Glomerular filtration rate declines • Serum creatinine misleading – • ‘occult’ renal insufficiency

  41. Fluid homeostasis • Sodium conservation impaired • Urine concentrating ability reduced • Thirst diminished Post operative Acute Renal Failure >50% mortality in very elderly patients

  42. Body Compartments • Decline in total body water • intracellular water • plasma volume maintained • Less lean tissue & skeletal muscle mass • Increase proportion of fat

  43. Hepatic • Decrease in hepatic mass • Decrease in hepatic clearance • Less albumin • Qualitative change in protein binding • Alpha-1-glycoprotein increases

  44. Drug considerations • water soluble drugs • prolonged half life of lipophilic drugs • decreased hepatic metabolism& renal clearance • increased target organ sensitivity

  45. Risk – What Dose?

  46. Summary pathophysiology • Steady decline in organ function • Unpredictable reserve function • Increased comorbidity

  47. Reserve Function Diminished

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