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Geriatric Patient
Hasanul-2004
At a cellular level,
(within mitochondria) DECREASED
ANTIOXIDANT &
OXIDATIVE SCAVENGING
STRESS CAPACITY
“CYLE OF
INCREASED AGING”
PROBABILITY OF
DEATH
INCREASED DAMAGE TO
INTRACELLULAR MEMBRANES,
FREE-RADICALS PROTEINS, &
GENETIC
INTEGRITY
LOSS OF
INCREASED TISSUE AND
SUSCEPTIBILITY TO DECREASED
ORGAN
DISEASE, INFECTION BIOENERGETIC
FUNCTIONAL
AND INJURY CAPACITY
RESERVE
Hasanul-2004
B. Safety margin organ system functional reserve to meet
additional demands (increased CO, CO2 excretion, protein
synthesis)
1. The functional reserve of all organ systems is
progressively and significantly decreased in elderly
patients.
2. Physiologic aging increased susceptibility of elderly
patients to stress and disease-induced organ system
decompensation .
Hasanul-2004
III. Cardiopulmonary function
A. Cardiac function,
1. The demand for cardiopulmonary function is maintained in
elderly patients by daily exercise.
2. Short-term increases in cardiac output are accomplished in
the elderly patient initially by modest increases in heart
rate and then by progressively larger stroke volume.
3. Aging decreases the inotropic and chronotropic responses
to neurally mediated adrenergic stimulation such that
maximum heart rate and inotropic response are age
limited.
4. Passive ventricular filling, which normally occurs during the
early phase of diastole, is decreased in elderly patients
(stiffer and less compliant ventricle)
Hasanul-2004
5. Age-related diastolic dysfunction elderly patients more
dependent on synchronous atrial contraction for
complete ventricular filling.
a. VR stroke volume compromise
b. Perioperative arterial hypotension is predictable
more common in elderly than in young.
6. Systolic arterial hypertension fibrotic replacement of
elastic tissue within the cardiovascular system.
B. Respiratory function
Fibrous connective tissue loss of lung elastic recoil
(inevitable emphysema-like changes)
1. FRC , VC , Residual Volume
2. Costochondral calcification thorax more rigid WoB
3. Age related acute postoperative ventilatory failure
4. Age related decrease in arterial oxygenation
Hasanul-2004
5. More vulnerable to developing transient apnea when given drug (opioid,
benzodiazepin) post operative.
6. The treshold stimulus needed for vocal cord closure
risk of aspiration of gastric content.
B.
1. Renal tissue mass decrease by about 30%, and RBF decreases by about
50% by the eighth decade of life.
2. Serum creatinine concentration usually remains within the normal
range.
3. Intravascular and intracellular dehydration
C.
Elderly patients exhibit decreased immune responsiveness
Hasanul-2004
V. METABOLISM, BODY COMPOSITION, AND PHARMACOKINETICS
A. Aging in men results in a progressive and generalized loss of skeletal
muscle mass and reciprocal increases in the lipid fraction
kg kg
MEN
80- - 80
WOMEN
70- - 70
BODY
60- LIPID - 60
50- OTHER
- 50
TISSUE
40- - 40
30- - 30
BODY
20- WATER
- 20
10- - 10
0 - -0
YOUNG OLDER YOUNG OLDER
Age related changes in body composition are gender specific. Increases in body fat offset bone loss and intracellular
dehydration in women, whereas in man accelerated loss of skeletal muscle and other component of lean tissue mass
produces contraction of intracellular water and a decrease in total body weight.
Hasanul-2004 Hand book of Clinical Anesthesia: Barash.PG, Cullen.BF, Stoelting.RK :2001, 654
1. BMR , heat production , special risk for intraoperative
hypothermia
• Intraoperative decreases in core body temperature average
almost 10C per hour.
• The time needed for postoperative spontaneous rewarming may
be prolonged.
2. Progressive impairment of the ability to handle an intravenous
glucose challenge hyperglycemia
B. Plasma volume, red cell mass, and ECF volumes are normally
well maintained in normotensive elderly individuals who
maintain their habits of daily physical activity.
C. Increases in total body lipid content enlarge the volume of
distribution of drugs (inhaled anesthetics, barbiturates,
benzodiazepin). This may delay recovery in elderly patients .
Hasanul-2004
VI. CENTRAL NERVOUS SYSTEM
A. Aging decreases brain size, and neurons that synthese
neurotransmitters (dopamine, norepinephrine, tyrosine,
serotonin) seem to be most affected.
B. CBF decreases in proportion to decreased brain tissue.
1. Autoregulation is well maintained, and the cerebral
vasoconstrictor response to hyperventilation remains
intact.
2. In the absence of cerebrovascular disease, the
conventional guidelines for controlled hypotension
during neurosurgical procedures are appropriate for
elderly.
C. Comprehension and long term memory are well maintained.
D. Hypothalamic-pituitary-adrenal dysregulation and increased
plasma cortisol levels.
Hasanul-2004
VII. PERIPHERAL NERVOUS SYSTEM
A. The treshold intensities of stimuli needed to initiate all
forms of perception are increased.
B. Aging is associated with a gradual but significant
deterioration of electrical conduction along efferent
motor pathway.
C. Cholinoreceptors at the skeletal muscle .
Hasanul-2004
VII. AUTONOMIC NERVOUS SYSTEM
A. Neurons in the sympathoadrenal pathways decline by at
least 15% by 80 years of age. Nevertheless, plasma nor-
epinephrine are significantly .
• Aging markedly and progressively depresses autonomic
end organ responsiveness
• Aging produces an endogenous ß blockade.
• Aging appears to produce little change in α-adrenergic
or muscarinic cholinoceptor activity.
Hasanul-2004
DOXACURIUM
PIPECURONIUM
METOCURINE
CURARE
PANCURONIUM
CISATRACURIUM
RI-OLDER ADULT
VECURONIUM RI-YOUNGER ADULT
ATRACURIUM
ROCURONIUM
MIVACURIUM
RECOVERY INDEX
I I I I I I I
(T25-T75, minutes)
0 20 40 60 80 100 120
RI : Recovery Index , the time required for spontaneous recovery from
25% to 75% of the control evoked neuromuscular response.
Hand book of Clinical Anesthesia: Barash.PG, Cullen.BF, Stoelting.RK :2001, 658
Hasanul-2004
X. PERIOPERATIVE MANAGEMENT AND
OUTCOME.
• antihypertensives
• antidepressants
• anticoagulants
• oral hypoglycemics
• corticosteroids
• beta-blockers
• sedatives
Hasanul-2004
B. Adverse surgical outcome show a predominance of
dysfunction of cardiac, pulmonary and renal
mechanisms, emphasizing the importance of
preoperative evaluation and preparation as it relates
to these organ systems.
C. The choice of anesthetic drug or technique does not
seem to influence the overall outcome in elderly
patients .
1. Newer intravenous drugs (remifentanil, cisatracurium)
minimize dependence on organ system functional
reserve, whereas newer inhaled anesthetics
(sevoflurane, desflurane) provide rapid recovery of
consciousness even in elderly patients
Hasanul-2004
2. Prompt and complete postoperative recovery of mental
function is particularly important in elderly.
Hasanul-2004
D. Anesthetic management is appropriate, surgical
convalescence uncomplicated, full return of
cognitive function to preoperative levels may require 5-
10 days.
Hasanul-2004
Terima Kasih !