The Geriatric Patient

1
The Geriatric Patient
2
Patients Over Age 65

• Represent 11.3 of population
• Account for
• 33 of health care costs
• 38 of hospital bed days
• 21 of inpatient surgical procedures
• Over 50 will have surgery before they die

3
Classifying Older People

• Elderly - Age 65 - 74
• Aged - Age 75 - 84
• Very old - Over age 85

4
Aging

• A progressive, universally prevalent physiologic
  process producing measurable changes in the
  structure and decremental alteration in the
  function of tissues and organs.
• (Miller, Anesthesia (4th ed.)

5

• Physiologic or functional age is not always
  consistent with chronological age
• Chronological age remains the best predictor of
  age related changes in organ systems or proximity
  to death

6
Body Composition Changes

• Anatomic
• increased lipid fraction
• loss of muscle mass
• Implication
• increased half life for lipid soluble drugs
• decreased O2 consumption, heat production
• decreased cardiac output

7
Nervous System Changes

• Anatomic
• loss of neurons
• reduced neurotransmitter activity
• Implication
• deafferentation
• neurologic atrophy
• decreased anesthetic requirement

8
Cardiovascular Changes

• Anatomic
• Decreased arterial elasticity
• Ventricular hypertrophy
• Reduced adrenergic responsiveness
• Implication
• Increased resistance to ejection
• wide pulse pressure
• decreased maximal cardiac output

9
Pulmonary Changes

• Anatomic
• Loss of lung elasticity
• Increased thoracic stiffness
• Reduced alveolar surface area
• Implication
• Increased residual volume
• Loss of vital capacity
• Impaired gas exchange
• Increased work of breathing

10
Reduced Oxygenation

• PaO2 102 - Age
• 3

11
Hepatic Changes

• Anatomic
• Reduced tissue mass
• Implication
• Reduced hepatic blood flow
• Reduced drug metabolism

12
Renal Changes

• Anatomic
• Reduced vascularity
• Tissue atrophy
• Implication
• Decreased plasma flow
• Decreased GFR
• Decreased drug clearance
• Decreased ability to handle salt and water loads

13
Common Procedures in Patients Over Age 65

• Thoracic or cardiac
• Orthopedic
• Craniotomy
• Genito urinary

14
Common Procedures in Patients Over Age 65
(Contd)

• Gynecologic
• Cataract
• Hernia repair
• Pacemaker insertion

15
Special concerns for the geriatric patient
16
Skin

• Loss of connective tissue
• Bruise easily
• Removing tape an electrodes may tear the skin
• Tourniquets and BP cuff may cause a bruise
• Heating pad may cause burn

17
Joints and Pressure Points

• Lithotomy position
• Nerve stretch injury
• Dislocation of prosthetic hip
• Lateral or Prone
• Brachial plexus injury
• Neck injury
• Eye injury

18
Difficult Airway

• Stiff neck and jaw
• Dental deterioration
• Difficult mask fit
• Risk for aspiration

19
Dose and Duration of Drugs

• Altered body composition
• Decreased blood volume
• Decreased muscle mass
• Decreased plasma proteins
• Slower circulatory time
• Reduced metabolism and clearance

20
Why are they always cold when they get to the
recovery room?
21
Surgical Patients Are

• Undressed
• Placed in a cold room
• Washed with a cool liquid
• Vasodilated

22
Altered Body Temperature

• BMR decreased 1 per year after age 30
• Decreased thermogenesis capability

23
Is Hypothermia Harmful?

• Shivering requires energy
• May cause myocardial ischemia
• Drug metabolism is slowed
• Note Expect elderly patients to be
  cold and plan to warm them

24
The Elderly Patient in the PACU
25
Complications to anesthesia may occur in almost
25 of patients in the PACU
26
Common PACU Complications

• Pain
• Nausea
• Respiratory
• Cardiovascular instability

27
PACU Complications (Contd)

• Temperature changes
• Fluid and electrolyte imbalance
• Drug interactions
• Cerebral dysfunction

28
Postoperative Pain

• 75 of postsurgical patients are undertreated for
  pain
• Early pain management reduces other immediate
  postoperative problems
• Strategies for postoperative pain control should
  be made prior to surgery

29
Geriatric Pain Control

• Local infiltration
• Intravenous narcotics
• Bolus
• PCA
• Epidural narcotics
• Non-Steroidal anti-inflammatory drugs

30
Complications to Pain Control

• Over sedation
• Respiratory depression
• Agitation
• Urinary retention

31
Nausea and Vomiting

• Most common cause for admission of outpatient
• Primary causes
• The surgical procedure
• Anesthetic agents
• Premature administration of liquids
• Motion
• Pain

32
Prevention of Nausea

• Delayed oral intake
• Delayed motion
• Pain control
• Anti-Emetic drugs

33
Respiratory Considerations

• Oxygen saturation of 90 or less occurs in 55 of
  PACU patients
• Up to 95 of these episodes go unrecognized by
  the staff
• Elderly patients tend to have a lower PaO2

34
Risk Factors for Hypoxemia

• Duration of anesthesia
• Surgical site
• Age of patient
• History of smoking
• Type of anesthesia

35
Other Respiratory Complications in the Elderly

• Bronchospasm
• COPD
• Allergy/anaphylaxis
• Pulmonary embolism
• Resuscitation
• Pulmonary edema
• Aspiration

36
Cardiovascular Problems

• Hypotension
• Residual anesthetic effect
• Lack of stimulation
• Fluid imbalance
• hypovolemia
• hypervolemia
• Post-op epidural
• Myocardial ischemia

37
Cardiovascular Problems (Contd)

• Hypertension
• Common in patients with arteriosclerosis
• Exaggerated response to pain
• All patients deserve pain control
• Pain may worsen ischemia
• Consider PCA
• Consider full bladder

38
Cardiovascular (Dysrhythmias)

• Causes
• Increased sympathetic activity
• Hypoxia
• Hypercarbia

39
Dysrhythmias

• Usually OK if rate 50 -90 and BP remains normal
• Watch for
• Bigeminy
• Coupled PVCs
• Re-entry phenomenon
• May need to rule out MI

40
Fluid and Electrolyte Imbalance

• Common problems in the elderly
• Third space shift
• Chronic anti-hypertensive treatment
• TURP syndrome (hyponatremia)

41
Drug Interactions in PACU

• Neuromuscular blocking effects of antibiotics are
  potentiated by Verapamil
• Diuresis hypokalemia
• Digitalis Toxicity
• Clearance of Dilantin is reduced in the presence
  of the blockers

42
Drug Interactions in PACU (Contd)

• Effects of Benzodiazepines and Propranolol are
  increased by Ranitidine
• Beta Blockers or Digitalis combined with calcium
  channel blockers may lead to heart block
• Ketamine plus Epinephrine may cause dysrhythmias

43
Drug Interactions in PACU (Contd)

• The hypotensive effect of Labetalol is enhanced
  by Cimetidine and Halothane
• Dilantin enhances the breakdown of Demerol
• Propranolol plus Neostigmine enhances bradycardia

44
Mental Status Changes

• Anatomic changes
• Reduced brain mass
• Cerebral sulci size increases
• Neuronal loss 50,000 per day
• Those producing neurotransmitters have the
  greatest loss
• Decreased short term memory, auditory and visual
  acuity

45
Post-Op Mental Deterioration

• Drug interaction or side effect
• Depression
• Cerebral vascular insufficiency
• Metabolic imbalance

46
Summary

• Elderly patients commonly have co-existing
  disease
• Despite our best effort, elderly patients
  commonly arrive in the PACU cold with abnormal BP
  and/or respirations

47
Summary (Contd)

• All patients deserve pain control
• With a little extra care, elderly patients can be
  safely managed throughout the perioperative period