J Korean Med Assoc.  2011 Mar;54(3):303-310.

Geriatric anesthesia in an aging society

• Lee JW
• Lee KY

Abstract

Aging is a process of the gradual reduction of functional reserve, and when it begins and how fast it proceeds are different from patient to patient. Therefore, it is important to thoroughly evaluate the current status of an elderly patient. Based on an in-depth understanding of pharmacokinetic and pharmacodynamic changes that occur due to aging, sophisticated titration of doses and infusion rates of drugs depending on the current functional status of the patient is essential for hemodynamic stability. Physicians must always keep in mind that the top priority of geriatric anesthetic management is the rapid return of functional independence. Therefore, wher-ever practical, it is prudent to use drug(s) of short duration, and metabolic processes not affected by the current disease and/or the proposed surgical procedures. Active preoperative assessment of cardiac and cerebrovascular risk factors and adequate postoperative pain relief are important to prevent postoperative cognitive dysfunction, which delays functional recovery.

Keyword

Aging; Anesthesia; Elderly patient

MeSH Terms

Aged
Aging
Anesthesia
Hemodynamics
Humans
Pain, Postoperative
Risk Factors

Reference

1. Korea National Statistical Office. Population projections for Korea 2001-2050: based on the 2005 population census. 2006. Daejeon: Korea National Statistical Office;43–45.

2. Sieber FE, Pauldine R. Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Young WL, editors. Geriatric anesthesia. Miller's anesthesia. 2010. Philadelphia: Churchill Livingstone;2261–2262.

3. Ge Y, Grossman RI, Babb JS, Rabin ML, Mannon LJ, Kolson DL. Age-related total gray matter and white matter changes in normal adult brain. Part I: volumetric MR imaging analysis. AJNR Am J Neuroradiol. 2002. 23:1327–1333.

4. Small SA. Age-related memory decline: current concepts and future directions. Arch Neurol. 2001. 58:360–364.

5. Tsui BC, Wagner A, Finucane B. Regional anaesthesia in the elderly: a clinical guide. Drugs Aging. 2004. 21:895–910.

6. Priebe HJ. The aged cardiovascular risk patient. Br J Anaesth. 2000. 85:763–778.

7. Brandes RP, Fleming I, Busse R. Endothelial aging. Cardiovasc Res. 2005. 66:286–294.

8. Frenneaux M, Williams L. Ventricular-arterial and ventricular-ventricular interactions and their relevance to diastolic filling. Prog Cardiovasc Dis. 2007. 49:252–262.

9. Rooke GA. Cardiovascular aging and anesthetic implications. J Cardiothorac Vasc Anesth. 2003. 17:512–523.

10. Rooke GA. Autonomic and cardiovascular function in the geriatric patient. Anesthesiol Clin North America. 2000. 18:31–46.

11. Chinnaiyan KM, Alexander D, Maddens M, McCullough PA. Curriculum in cardiology: integrated diagnosis and management of diastolic heart failure. Am Heart J. 2007. 153:189–200.

12. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Md RN, Ornato JP, Page RL, Tarkington LG, Yancy CW. ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation. 2007. 116:1971–1996.

13. Iakovou I, Schmidt T, Bonizzoni E, Ge L, Sangiorgi GM, Stankovic G, Airoldi F, Chieffo A, Montorfano M, Carlino M, Michev I, Corvaja N, Briguori C, Gerckens U, Grube E, Colombo A. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA. 2005. 293:2126–2130.

14. Heir JS, Gottumukkala V, Singh M, Yusuf SW, Riedel B. Coronary stents and noncardiac surgery: current clinical challenges and conundrums. Prev Cardiol. 2010. 13:8–13.

15. Zaugg M, Lucchinetti E. Respiratory function in the elderly. Anesthesiol Clin North America. 2000. 18:47–58.

16. Fredman B, Lahav M, Zohar E, Golod M, Paruta I, Jedeikin R. The effect of midazolam premedication on mental and psychomotor recovery in geriatric patients undergoing brief surgical procedures. Anesth Analg. 1999. 89:1161–1166.

17. Nunn JF. Nunn's applied respiratory physiology. 1993. 4th ed. Oxford: Butterworth-Heinemann.

18. Epstein M. Aging and the kidney. J Am Soc Nephrol. 1996. 7:1106–1122.

19. Martin JE, Sheaff MT. Renal ageing. J Pathol. 2007. 211:198–205.

20. Schmucker DL. Age-related changes in liver structure and function: implications for disease? Exp Gerontol. 2005. 40:650–659.

21. Shafer SL. The pharmacology of anesthetic drugs in elderly patients. Anesthesiol Clin North America. 2000. 18:1–29.

22. Sadean MR, Glass PS. Pharmacokinetics in the elderly. Best Pract Res Clin Anaesthesiol. 2003. 17:191–205.

23. Vuyk J. Pharmacodynamics in the elderly. Best Pract Res Clin Anaesthesiol. 2003. 17:207–218.

24. Eger EI 2nd. Age, minimum alveolar anesthetic concentration, and minimum alveolar anesthetic concentration-awake. Anesth Analg. 2001. 93:947–953.

25. Homer TD, Stanski DR. The effect of increasing age on thiopental disposition and anesthetic requirement. Anesthesiology. 1985. 62:714–724.

26. Arden JR, Holley FO, Stanski DR. Increased sensitivity to etomidate in the elderly: initial distribution versus altered brain response. Anesthesiology. 1986. 65:19–27.

27. Schnider TW, Minto CF, Shafer SL, Gambus PL, Andresen C, Goodale DB, Youngs EJ. The influence of age on propofol pharmacodynamics. Anesthesiology. 1999. 90:1502–1516.

28. Bell GD, Spickett GP, Reeve PA, Morden A, Logan RF. Intravenous midazolam for upper gastrointestinal endoscopy: a study of 800 consecutive cases relating dose to age and sex of patient. Br J Clin Pharmacol. 1987. 23:241–243.

29. Minto CF, Schnider TW, Egan TD, Youngs E, Lemmens HJ, Gambus PL, Billard V, Hoke JF, Moore KH, Hermann DJ, Muir KT, Mandema JW, Shafer SL. Influence of age and gender on the pharmacokinetics and pharmacodynamics of remifentanil. I. Model development. Anesthesiology. 1997. 86:10–23.

30. Macintyre PE, Jarvis DA. Age is the best predictor of postoperative morphine requirements. Pain. 1996. 64:357–364.

31. Cope TM, Hunter JM. Selecting neuromuscular-blocking drugs for elderly patients. Drugs Aging. 2003. 20:125–140.

32. Veering BT, Burm AG, Spierdijk J. Spinal anaesthesia with hyperbaric bupivacaine. Effects of age on neural blockade and pharmacokinetics. Br J Anaesth. 1988. 60:187–194.

33. Veering BT, Burm AG, van Kleef JW, Hennis PJ, Spierdijk J. Epidural anesthesia with bupivacaine: effects of age on neural blockade and pharmacokinetics. Anesth Analg. 1987. 66:589–593.

34. Liu LL, Leung JM. Predicting adverse postoperative outcomes in patients aged 80 years or older. J Am Geriatr Soc. 2000. 48:405–412.

35. Michelsen LG, Hug CC Jr. The pharmacokinetics of remifentanil. J Clin Anesth. 1996. 8:679–682.

36. Rosenfeld BA, Beattie C, Christopherson R, Norris EJ, Frank SM, Breslow MJ, Rock P, Parker SD, Gottlieb SO, Perler BA. Perioperative Ischemia Randomized Anesthesia Trial Study Group. The effects of different anesthetic regimens on fibrinolysis and the development of postoperative arterial thrombosis. Anesthesiology. 1993. 79:435–443.

37. Wu CL, Hsu W, Richman JM, Raja SN. Postoperative cognitive function as an outcome of regional anesthesia and analgesia. Reg Anesth Pain Med. 2004. 29:257–268.

38. Seymour DG, Vaz FG. A prospective study of elderly general surgical patients. II. Post-operative complications. Age Ageing. 1989. 18:316–326.

39. Mitchell CK, Smoger SH, Pfeifer MP, Vogel RL, Pandit MK, Donnelly PJ, Garrison RN, Rothschild MA. Multivariate analysis of factors associated with postoperative pulmonary complications following general elective surgery. Arch Surg. 1998. 133:194–198.

40. Aviv JE. Effects of aging on sensitivity of the pharyngeal and supraglottic areas. Am J Med. 1997. 103:74S–76S.

41. Washington LL, Gibson SJ, Helme RD. Age-related differences in the endogenous analgesic response to repeated cold water immersion in human volunteers. Pain. 2000. 89:89–96.

42. Vaurio LE, Sands LP, Wang Y, Mullen EA, Leung JM. Postoperative delirium: the importance of pain and pain management. Anesth Analg. 2006. 102:1267–1273.

43. Egbert AM. Postoperative pain management in the frail elderly. Clin Geriatr Med. 1996. 12:583–599.

44. Moller JT, Cluitmans P, Rasmussen LS, Houx P, Rasmussen H, Canet J, Rabbitt P, Jolles J, Larsen K, Hanning CD, Langeron O, Johnson T, Lauven PM, Kristensen PA, Biedler A, van Beem H, Fraidakis O, Silverstein JH, Beneken JE, Gravenstein JS. Long-term postoperative cognitive dysfunction in the elderly ISPOCD1 study. ISPOCD investigators. International Study of Post-Operative Cognitive Dysfunction. Lancet. 1998. 351:857–861.

45. Johnson T, Monk T, Rasmussen LS, Abildstrom H, Houx P, Korttila K, Kuipers HM, Hanning CD, Siersma VD, Kristensen D, Canet J, Ibanaz MT, Moller JT. Postoperative cognitive dysfunction in middle-aged patients. Anesthesiology. 2002. 96:1351–1357.

46. Abildstrom H, Rasmussen LS, Rentowl P, Hanning CD, Rasmussen H, Kristensen PA, Moller JT. Cognitive dysfunction 1-2 years after non-cardiac surgery in the elderly. ISPOCD group. International Study of Post-Operative Cognitive Dysfunction. Acta Anaesthesiol Scand. 2000. 44:1246–1251.

47. Selnes OA, Grega MA, Borowicz LM Jr, Barry S, Zeger S, Baumgartner WA, McKhann GM. Cognitive outcomes three years after coronary artery bypass surgery: a comparison of on-pump coronary artery bypass graft surgery and nonsurgical controls. Ann Thorac Surg. 2005. 79:1201–1209.

48. Newman MF, Kirchner JL, Phillips-Bute B, Gaver V, Grocott H, Jones RH, Mark DB, Reves JG, Blumenthal JA. Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. N Engl J Med. 2001. 344:395–402.