UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Anesthesia for the older adult

Author
Sheila Barnett, MD
Section Editor
Girish P Joshi, MB, BS, MD, FFARCSI
Deputy Editor
Nancy A Nussmeier, MD, FAHA

INTRODUCTION

Older adults (≥65 years of age) account for a disproportionately large fraction of all surgical procedures performed in the United States (figure 1) [1,2]. Older age is a risk factor for perioperative mortality, but preoperative comorbidity and invasiveness of the surgical procedure are other important predictors of mortality in this age group [3-9]. The American Society of Anesthesiologists (ASA) Physical Status score (table 1) [10], indicating severe systemic disease, is an established predictor of adverse outcomes after surgery in patients of all ages but does not specify age as a factor [3-6].

This topic will discuss age-related physiologic changes that affect anesthetic drugs and techniques, optimal perioperative anesthetic management, and risk factors for complications in older patients.

IMPACT OF AGE-RELATED PHYSIOLOGIC CHANGES ON ANESTHETIC CARE

Aging is associated with a progressive loss of functional reserve in all organ systems (see "Normal aging"). However, there is considerable individual variability in the onset and extent of these changes. Nevertheless, even the healthy older adult has reduced physiologic reserve, and organ systems may be compromised during illness and/or surgical stress. The following physiologic changes specifically impact anesthetic care, in large part by increasing susceptibility to anesthetic drugs [11].

Nervous system — Age-related changes in the central and peripheral nervous system affect the older adult's response to anesthetics and other medications, as well as the perception of pain.

Central nervous system changes include reduction in brain size and neuronal density and widening of the sulci and ventricles. Regional reductions in neurotransmitters (eg, dopamine, serotonin, and acetylcholine) and neuroreceptors may occur [12].

                                        

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Wed Aug 10 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Neuman MD, Bosk CL. The redefinition of aging in American surgery. Milbank Q 2013; 91:288.
  2. The Anesthesia Quality Institute. Anesthesia in the US 2012. Available at: https://ecommerce.asahq.org/p-556-anesthesia-in-the-united-states-2012.aspx?. (Accessed on July 07, 2013).
  3. Hamel MB, Henderson WG, Khuri SF, Daley J. Surgical outcomes for patients aged 80 and older: morbidity and mortality from major noncardiac surgery. J Am Geriatr Soc 2005; 53:424.
  4. Turrentine FE, Wang H, Simpson VB, Jones RS. Surgical risk factors, morbidity, and mortality in elderly patients. J Am Coll Surg 2006; 203:865.
  5. Pedersen T, Eliasen K, Henriksen E. A prospective study of mortality associated with anaesthesia and surgery: risk indicators of mortality in hospital. Acta Anaesthesiol Scand 1990; 34:176.
  6. Hosking MP, Warner MA, Lobdell CM, et al. Outcomes of surgery in patients 90 years of age and older. JAMA 1989; 261:1909.
  7. Kheterpal S, O'Reilly M, Englesbe MJ, et al. Preoperative and intraoperative predictors of cardiac adverse events after general, vascular, and urological surgery. Anesthesiology 2009; 110:58.
  8. Chung F, Mezei G, Tong D. Adverse events in ambulatory surgery. A comparison between elderly and younger patients. Can J Anaesth 1999; 46:309.
  9. Fleisher LA, Pasternak LR, Herbert R, Anderson GF. Inpatient hospital admission and death after outpatient surgery in elderly patients: importance of patient and system characteristics and location of care. Arch Surg 2004; 139:67.
  10. American Society of Anesthesiologists. ASA Physical Status Classification System. Available at: http://www.asahq.org/For-Members/Clinical-Information/ASA-Physical-Status-Classification-System.aspx (Accessed on October 23, 2013).
  11. Rivera R, Antognini JF. Perioperative drug therapy in elderly patients. Anesthesiology 2009; 110:1176.
  12. Peters R. Ageing and the brain. Postgrad Med J 2006; 82:84.
  13. Nickalls RW, Mapleson WW. Age-related iso-MAC charts for isoflurane, sevoflurane and desflurane in man. Br J Anaesth 2003; 91:170.
  14. Lawrence VA, Cornell JE, Smetana GW, American College of Physicians. Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med 2006; 144:596.
  15. Hasukić S, Mesić D, Dizdarević E, et al. Pulmonary function after laparoscopic and open cholecystectomy. Surg Endosc 2002; 16:163.
  16. Karayiannakis AJ, Makri GG, Mantzioka A, et al. Postoperative pulmonary function after laparoscopic and open cholecystectomy. Br J Anaesth 1996; 77:448.
  17. Verdú E, Ceballos D, Vilches JJ, Navarro X. Influence of aging on peripheral nerve function and regeneration. J Peripher Nerv Syst 2000; 5:191.
  18. Gibson SJ, Farrell M. A review of age differences in the neurophysiology of nociception and the perceptual experience of pain. Clin J Pain 2004; 20:227.
  19. Silverstein JH, Timberger M, Reich DL, Uysal S. Central nervous system dysfunction after noncardiac surgery and anesthesia in the elderly. Anesthesiology 2007; 106:622.
  20. Rooke GA. Cardiovascular aging and anesthetic implications. J Cardiothorac Vasc Anesth 2003; 17:512.
  21. Das S, Forrest K, Howell S. General anaesthesia in elderly patients with cardiovascular disorders: choice of anaesthetic agent. Drugs Aging 2010; 27:265.
  22. Phillip B, Pastor D, Bellows W, Leung JM. The prevalence of preoperative diastolic filling abnormalities in geriatric surgical patients. Anesth Analg 2003; 97:1214.
  23. Groban L. Diastolic dysfunction in the older heart. J Cardiothorac Vasc Anesth 2005; 19:228.
  24. Groban L, Butterworth J. Perioperative management of chronic heart failure. Anesth Analg 2006; 103:557.
  25. Sprung J, Gajic O, Warner DO. Review article: age related alterations in respiratory function - anesthetic considerations. Can J Anaesth 2006; 53:1244.
  26. Smetana GW, Lawrence VA, Cornell JE, American College of Physicians. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med 2006; 144:581.
  27. Shafer SL. The pharmacology of anesthetic drugs in elderly patients. Anesthesiol Clin North America 2000; 18:1.
  28. McLean AJ, Le Couteur DG. Aging biology and geriatric clinical pharmacology. Pharmacol Rev 2004; 56:163.
  29. Esposito C, Plati A, Mazzullo T, et al. Renal function and functional reserve in healthy elderly individuals. J Nephrol 2007; 20:617.
  30. Giannelli SV, Patel KV, Windham BG, et al. Magnitude of underascertainment of impaired kidney function in older adults with normal serum creatinine. J Am Geriatr Soc 2007; 55:816.
  31. Chau DL, Walker V, Pai L, Cho LM. Opiates and elderly: use and side effects. Clin Interv Aging 2008; 3:273.
  32. Schmucker DL. Age-related changes in liver structure and function: Implications for disease ? Exp Gerontol 2005; 40:650.
  33. Minto CF, Schnider TW, Egan TD, et al. Influence of age and gender on the pharmacokinetics and pharmacodynamics of remifentanil. I. Model development. Anesthesiology 1997; 86:10.
  34. Lubin MF. Is age a risk factor for surgery? Med Clin North Am 1993; 77:327.
  35. Committee on Standards and Practice Parameters, Apfelbaum JL, Connis RT, et al. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2012; 116:522.
  36. Schein OD, Katz J, Bass EB, et al. The value of routine preoperative medical testing before cataract surgery. Study of Medical Testing for Cataract Surgery. N Engl J Med 2000; 342:168.
  37. Gold BS, Young ML, Kinman JL, et al. The utility of preoperative electrocardiograms in the ambulatory surgical patient. Arch Intern Med 1992; 152:301.
  38. Goldberger AL, O'Konski M. Utility of the routine electrocardiogram before surgery and on general hospital admission. Critical review and new guidelines. Ann Intern Med 1986; 105:552.
  39. Leung JM, Dzankic S. Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients. J Am Geriatr Soc 2001; 49:1080.
  40. Noordzij PG, Boersma E, Bax JJ, et al. Prognostic value of routine preoperative electrocardiography in patients undergoing noncardiac surgery. Am J Cardiol 2006; 97:1103.
  41. Liu LL, Dzankic S, Leung JM. Preoperative electrocardiogram abnormalities do not predict postoperative cardiac complications in geriatric surgical patients. J Am Geriatr Soc 2002; 50:1186.
  42. Burda SA, Hobson D, Pronovost PJ. What is the patient really taking? Discrepancies between surgery and anesthesiology preoperative medication histories. Qual Saf Health Care 2005; 14:414.
  43. Qato DM, Alexander GC, Conti RM, et al. Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. JAMA 2008; 300:2867.
  44. Hayes BD, Klein-Schwartz W, Barrueto F Jr. Polypharmacy and the geriatric patient. Clin Geriatr Med 2007; 23:371.
  45. Juurlink DN, Mamdani M, Kopp A, et al. Drug-drug interactions among elderly patients hospitalized for drug toxicity. JAMA 2003; 289:1652.
  46. Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 2003; 289:1107.
  47. Kheterpal S, Khodaparast O, Shanks A, et al. Chronic angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy combined with diuretic therapy is associated with increased episodes of hypotension in noncardiac surgery. J Cardiothorac Vasc Anesth 2008; 22:180.
  48. Rosenman DJ, McDonald FS, Ebbert JO, et al. Clinical consequences of withholding versus administering renin-angiotensin-aldosterone system antagonists in the preoperative period. J Hosp Med 2008; 3:319.
  49. van den Bemt PM, van den Broek S, van Nunen AK, et al. Medication reconciliation performed by pharmacy technicians at the time of preoperative screening. Ann Pharmacother 2009; 43:868.
  50. Makary MA, Segev DL, Pronovost PJ, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg 2010; 210:901.
  51. Kim SW, Han HS, Jung HW, et al. Multidimensional frailty score for the prediction of postoperative mortality risk. JAMA Surg 2014; 149:633.
  52. Urwin SC, Parker MJ, Griffiths R. General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomized trials. Br J Anaesth 2000; 84:450.
  53. Chu CC, Weng SF, Chen KT, et al. Propensity Score-matched Comparison of Postoperative Adverse Outcomes between Geriatric Patients Given a General or a Neuraxial Anesthetic for Hip Surgery: A Population-based Study. Anesthesiology 2015; 123:136.
  54. Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000; 321:1493.
  55. Nishimori M, Low JH, Zheng H, Ballantyne JC. Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery. Cochrane Database Syst Rev 2012; :CD005059.
  56. Matot I, Oppenheim-Eden A, Ratrot R, et al. Preoperative cardiac events in elderly patients with hip fracture randomized to epidural or conventional analgesia. Anesthesiology 2003; 98:156.
  57. Hausman MS Jr, Jewell ES, Engoren M. Regional versus general anesthesia in surgical patients with chronic obstructive pulmonary disease: does avoiding general anesthesia reduce the risk of postoperative complications? Anesth Analg 2015; 120:1405.
  58. van Lier F, van der Geest PJ, Hoeks SE, et al. Epidural analgesia is associated with improved health outcomes of surgical patients with chronic obstructive pulmonary disease. Anesthesiology 2011; 115:315.
  59. Guay J, Choi P, Suresh S, et al. Neuraxial blockade for the prevention of postoperative mortality and major morbidity: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev 2014; :CD010108.
  60. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2215.
  61. Brown CH 4th, Azman AS, Gottschalk A, et al. Sedation depth during spinal anesthesia and survival in elderly patients undergoing hip fracture repair. Anesth Analg 2014; 118:977.
  62. Williams-Russo P, Sharrock NE, Mattis S, et al. Cognitive effects after epidural vs general anesthesia in older adults. A randomized trial. JAMA 1995; 274:44.
  63. Rasmussen LS, Johnson T, Kuipers HM, et al. Does anaesthesia cause postoperative cognitive dysfunction? A randomised study of regional versus general anaesthesia in 438 elderly patients. Acta Anaesthesiol Scand 2003; 47:260.
  64. Clarke GA, Jacobson BC, Hammett RJ, Carr-Locke DL. The indications, utilization and safety of gastrointestinal endoscopy in an extremely elderly patient cohort. Endoscopy 2001; 33:580.
  65. Lukens FJ, Loeb DS, Machicao VI, et al. Colonoscopy in octogenarians: a prospective outpatient study. Am J Gastroenterol 2002; 97:1722.
  66. Rodríguez-González FJ, Naranjo-Rodríguez A, Mata-Tapia I, et al. ERCP in patients 90 years of age and older. Gastrointest Endosc 2003; 58:220.
  67. American Society of Anesthesiologists. Position on Monitored Anesthesia Care. September 2008.
  68. Wang CY, Ling LC, Cardosa MS, et al. Hypoxia during upper gastrointestinal endoscopy with and without sedation and the effect of pre-oxygenation on oxygen saturation. Anaesthesia 2000; 55:654.
  69. ASGE Technology Committee. Monitoring equipment for endoscopy. Gastrointest Endosc 2004; 59:761.
  70. Marik PE, Kaplan D. Aspiration pneumonia and dysphagia in the elderly. Chest 2003; 124:328.
  71. American Society of Anesthesiologists. Standards for Basic Anesthetic Monitoring. July 2011.
  72. Cockings JG, Webb RK, Klepper ID, et al. The Australian Incident Monitoring Study. Blood pressure monitoring--applications and limitations: an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21:565.
  73. Sandham JD, Hull RD, Brant RF, et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 2003; 348:5.
  74. American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. Practice guidelines for pulmonary artery catheterization: an updated report by the American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. Anesthesiology 2003; 99:988.
  75. American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 2010; 112:1084.
  76. American Society of Anesthesiologists Task Force on Intraoperative Awareness. Practice advisory for intraoperative awareness and brain function monitoring: a report by the american society of anesthesiologists task force on intraoperative awareness. Anesthesiology 2006; 104:847.
  77. Grocott MP, Mythen MG, Gan TJ. Perioperative fluid management and clinical outcomes in adults. Anesth Analg 2005; 100:1093.
  78. Adedeji R, Oragui E, Khan W, Maruthainar N. The importance of correct patient positioning in theatres and implications of mal-positioning. J Perioper Pract 2010; 20:143.
  79. SCIP-Inf-7. QualityNet website. Available at: www.qualitynet.org (Accessed on July 04, 2013).
  80. Karalapillai D, Story D, Hart GK, et al. Postoperative hypothermia and patient outcomes after major elective non-cardiac surgery. Anaesthesia 2013; 68:605.
  81. Frank SM, Fleisher LA, Breslow MJ, et al. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial. JAMA 1997; 277:1127.
  82. Schnider TW, Minto CF, Shafer SL, et al. The influence of age on propofol pharmacodynamics. Anesthesiology 1999; 90:1502.
  83. Jacobs JR, Reves JG, Marty J, et al. Aging increases pharmacodynamic sensitivity to the hypnotic effects of midazolam. Anesth Analg 1995; 80:143.
  84. Kirkbride DA, Parker JL, Williams GD, Buggy DJ. Induction of anesthesia in the elderly ambulatory patient: a double-blinded comparison of propofol and sevoflurane. Anesth Analg 2001; 93:1185.
  85. John AD, Sieber FE. Age associated issues: geriatrics. Anesthesiol Clin North America 2004; 22:45.
  86. Chan CM, Mitchell AL, Shorr AF. Etomidate is associated with mortality and adrenal insufficiency in sepsis: a meta-analysis*. Crit Care Med 2012; 40:2945.
  87. Lundy JB, Slane ML, Frizzi JD. Acute adrenal insufficiency after a single dose of etomidate. J Intensive Care Med 2007; 22:111.
  88. Jabre P, Combes X, Lapostolle F, et al. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Lancet 2009; 374:293.
  89. Schenarts CL, Burton JH, Riker RR. Adrenocortical dysfunction following etomidate induction in emergency department patients. Acad Emerg Med 2001; 8:1.
  90. Bruder EA, Ball IM, Ridi S, et al. Single induction dose of etomidate versus other induction agents for endotracheal intubation in critically ill patients. Cochrane Database Syst Rev 2015; 1:CD010225.
  91. Absalom A, Pledger D, Kong A. Adrenocortical function in critically ill patients 24 h after a single dose of etomidate. Anaesthesia 1999; 54:861.
  92. Komatsu R, You J, Mascha EJ, et al. Anesthetic induction with etomidate, rather than propofol, is associated with increased 30-day mortality and cardiovascular morbidity after noncardiac surgery. Anesth Analg 2013; 117:1329.
  93. Mapleson WW. Effect of age on MAC in humans: a meta-analysis. Br J Anaesth 1996; 76:179.
  94. Eger EI 2nd. Age, minimum alveolar anesthetic concentration, and minimum alveolar anesthetic concentration-awake. Anesth Analg 2001; 93:947.
  95. Macintyre PE, Jarvis DA. Age is the best predictor of postoperative morphine requirements. Pain 1996; 64:357.
  96. Cepeda MS, Farrar JT, Baumgarten M, et al. Side effects of opioids during short-term administration: effect of age, gender, and race. Clin Pharmacol Ther 2003; 74:102.
  97. Cedborg AI, Sundman E, Bodén K, et al. Pharyngeal function and breathing pattern during partial neuromuscular block in the elderly: effects on airway protection. Anesthesiology 2014; 120:312.
  98. McDonagh DL, Benedict PE, Kovac AL, et al. Efficacy, safety, and pharmacokinetics of sugammadex for the reversal of rocuronium-induced neuromuscular blockade in elderly patients. Anesthesiology 2011; 114:318.
  99. Gibson SJ, Helme RD. Age-related differences in pain perception and report. Clin Geriatr Med 2001; 17:433.
  100. Aubrun F. Management of postoperative analgesia in elderly patients. Reg Anesth Pain Med 2005; 30:363.
  101. Fong HK, Sands LP, Leung JM. The role of postoperative analgesia in delirium and cognitive decline in elderly patients: a systematic review. Anesth Analg 2006; 102:1255.
  102. Vaurio LE, Sands LP, Wang Y, et al. Postoperative delirium: the importance of pain and pain management. Anesth Analg 2006; 102:1267.
  103. Cohen-Mansfield J, Lipson S. Pain in cognitively impaired nursing home residents: how well are physicians diagnosing it? J Am Geriatr Soc 2002; 50:1039.
  104. Gagliese L, Weizblit N, Ellis W, Chan VW. The measurement of postoperative pain: a comparison of intensity scales in younger and older surgical patients. Pain 2005; 117:412.
  105. Aubrun F, Monsel S, Langeron O, et al. Postoperative titration of intravenous morphine in the elderly patient. Anesthesiology 2002; 96:17.
  106. Aubrun F, Bunge D, Langeron O, et al. Postoperative morphine consumption in the elderly patient. Anesthesiology 2003; 99:160.
  107. Gagliese L, Jackson M, Ritvo P, et al. Age is not an impediment to effective use of patient-controlled analgesia by surgical patients. Anesthesiology 2000; 93:601.
  108. Remy C, Marret E, Bonnet F. Effects of acetaminophen on morphine side-effects and consumption after major surgery: meta-analysis of randomized controlled trials. Br J Anaesth 2005; 94:505.
  109. Macario A, Lipman AG. Ketorolac in the era of cyclo-oxygenase-2 selective nonsteroidal anti-inflammatory drugs: a systematic review of efficacy, side effects, and regulatory issues. Pain Med 2001; 2:336.
  110. Zenilman ME, Chow WB, Ko CY, et al. New developments in geriatric surgery. Curr Probl Surg 2011; 48:670.
  111. Hammill BG, Curtis LH, Bennett-Guerrero E, et al. Impact of heart failure on patients undergoing major noncardiac surgery. Anesthesiology 2008; 108:559.
  112. van Diepen S, Bakal JA, McAlister FA, Ezekowitz JA. Mortality and readmission of patients with heart failure, atrial fibrillation, or coronary artery disease undergoing noncardiac surgery: an analysis of 38 047 patients. Circulation 2011; 124:289.
  113. Liu LL, Leung JM. Predicting adverse postoperative outcomes in patients aged 80 years or older. J Am Geriatr Soc 2000; 48:405.
  114. Li G, Warner M, Lang BH, et al. Epidemiology of anesthesia-related mortality in the United States, 1999-2005. Anesthesiology 2009; 110:759.
  115. Kheterpal S, Tremper KK, Heung M, et al. Development and validation of an acute kidney injury risk index for patients undergoing general surgery: results from a national data set. Anesthesiology 2009; 110:505.
  116. Evans BA, Wijdicks EF. High-grade carotid stenosis detected before general surgery: is endarterectomy indicated? Neurology 2001; 57:1328.
  117. Moller JT, Cluitmans P, Rasmussen LS, et al. Long-term postoperative cognitive dysfunction in the elderly ISPOCD1 study. ISPOCD investigators. International Study of Post-Operative Cognitive Dysfunction. Lancet 1998; 351:857.
  118. Monk TG, Weldon BC, Garvan CW, et al. Predictors of cognitive dysfunction after major noncardiac surgery. Anesthesiology 2008; 108:18.
  119. Crosby G, Culley DJ, Hyman BT. Preoperative cognitive assessment of the elderly surgical patient: a call for action. Anesthesiology 2011; 114:1265.
  120. Evered LA, Silbert BS, Scott DA, et al. Preexisting cognitive impairment and mild cognitive impairment in subjects presenting for total hip joint replacement. Anesthesiology 2011; 114:1297.
  121. Lawrence VA, Hazuda HP, Cornell JE, et al. Functional independence after major abdominal surgery in the elderly. J Am Coll Surg 2004; 199:762.