Geriatric Anesthesia: Concerns & Advancements

Geriatric patients exhibit unique physiological changes that affect drug metabolism and sensitivity and require a specialized specialized to anesthesia.

They are more prone to postoperative complications, such as cardiovascular, pulmonary issues, and cognitive impairments like postoperative cognitive dysfunction (POCD). Additionally, multiple chronic conditions and polypharmacy further complicate anesthesia management in this population.

Demographic trends showing rise in geriatric anesthesia

  • The number of Americans over the age of 70 has more than doubled since 1975 (NCBI).
  • In 2019, people aged 65 years and older represented 16% of the U.S. population (Saudi Journal of Anesthesia).
  • The population aged 65 years and older increased by 34.2% in the US since 2011 and now accounts for a disproportionate number of surgical procedures requiring anesthesia. (Journal of American Medical Association).

Physiological changes in elderly adults that impact geriatric anesthesia procedures

Aging brings about significant physiological changes that impact the way older adults respond to anesthesia. One of the most critical changes is the decrease in organ function and reserve capacity. As individuals age, their cardiac output declines, and their heart becomes less responsive to stress, which can complicate the management of blood pressure and cardiac function during surgery. 

Pulmonary function also deteriorates with age, which means that elderly patients have reduced lung capacity and elasticity. This makes elderly patients more susceptible to respiratory complications while under anesthesia.

Another major concern is the altered drug metabolism and sensitivity in older adults. The liver, which is primarily responsible for drug metabolism, experiences a decline in both size and blood flow with age, resulting in slower drug clearance from the body. Additionally, kidney function diminishes, affecting the excretion of anesthetic agents and other medications. These changes necessitate careful dosing and monitoring to avoid adverse drug reactions. 

Older adults often have a heightened sensitivity to drugs and anesthetics, due to changes in their receptor sensitivity and a decrease in the body’s ability to maintain homeostasis. These physiological changes highlight the need for tailored geriatric anesthetic approaches that consider the unique pharmacokinetics and pharmacodynamics in elderly patients to ensure their safety and well-being during and after surgical procedures.

Postoperative cognitive dysfunction (POCD) in elderly patients

Postoperative cognitive dysfunction (POCD) refers to the decline in cognitive function in patients that occurs after surgery. It is a significant concern in geriatric anesthesia management since POCD is particularly prevalent among elderly patients, who are more susceptible to cognitive changes due to the aging brain’s reduced resilience to stress and injury. 

POCD can manifest as impairments in memory, attention, and executive function, which may be temporary or, in some cases, long-lasting, significantly affecting the quality of life and independence of older adults.

The incidence of POCD is higher in elderly patients due to several factors:

  • The aging brain is more vulnerable to the inflammatory response and stress associated with surgery and anesthesia. 
  • Preexisting cognitive impairment or mild cognitive dysfunction, which might not have been clinically evident before surgery, can be exacerbated by the perioperative stress.
  • The concurrent use of multiple medications, known as polypharmacy, is a common issue among elderly patients and presents significant challenges in geriatric anesthesia. Polypharmacy increases the risk of drug-drug interactions and adverse drug reactions, complicating perioperative management and geriatric anesthesia care.

Preventing and managing POCD requires a multifaceted approach. Preoperative cognitive screening is essential to identify at-risk individuals and to tailor perioperative care accordingly. Employing anesthetic techniques that minimize neuroinflammation, such as using regional anesthesia where appropriate, can also help mitigate the risk of POCD.

Postoperative strategies to enhance recovery include:

  • Early mobilization
  • Adequate pain control
  • Cognitive rehabilitation

Introduction to strategies for improvement

The management of anesthesia for geriatric patients is fraught with unique challenges due to the physiological changes associated with aging, the higher prevalence of comorbidities, and the complexities introduced by polypharmacy. To optimize surgical outcomes and enhance the overall well-being of elderly patients, it is imperative to implement strategies that address these specific challenges. 

Effective perioperative care for older adults requires a comprehensive and multifaceted approach, involving:

  • Tailored anesthetic plans
  • Thorough geriatric assessments (especially preoperative)
  • Evidence-based recovery protocols

Comprehensive geriatric assessments improve patient outcomes

A comprehensive geriatric assessment (CGA) is crucial for optimizing perioperative care in elderly patients. This multidimensional evaluation assesses medical, psychological, and functional capabilities to ensure a holistic understanding of the patient’s health. The primary goal of CGA is to identify vulnerabilities that could affect surgical outcomes and develop individualized care plans. It begins with a detailed medical history and physical examination, focusing on chronic conditions, medication use, and prior surgical experiences to detect common comorbidities like cardiovascular disease, diabetes, and renal insufficiency. Additionally, reviewing the patient’s medication regimen helps identify potential drug interactions and the need for dosage adjustments, reducing the risk of adverse drug reactions during the perioperative period.

Psychological and functional assessments are also integral components of CGA. Cognitive assessments, using tools like the Mini-Mental State Examination (MMSE) or the Montreal Cognitive Assessment (MoCA), help identify impairments that can impact preoperative compliance and increase the risk of postoperative cognitive complications such as delirium and POCD. 

Functional assessments evaluate the patient’s ability to perform activities of daily living (ADLs) and their level of independence, focusing on mobility, balance, and muscle strength, essential for postoperative recovery and rehabilitation. Social and environmental factors are also considered to ensure adequate postoperative support. By incorporating CGA into perioperative care, healthcare providers can create tailored anesthetic and surgical plans, enhancing patient safety, surgical outcomes, and overall quality of care for elderly patients.

Tailored anesthetic approaches for geriatric patients

Tailored anesthetic approaches for geriatric patients are crucial for optimizing perioperative care, considering the unique physiological changes and health conditions associated with aging. These strategies aim to minimize risks and enhance recovery by addressing the specific needs of older adults. 

Individualized anesthetic plans are developed based on comprehensive assessments of the patient’s health status, including comorbidities, functional capacity, and medication use. Choosing the right type of anesthesia is a key aspect, with regional anesthesia often being preferred over general anesthesia to reduce the risks of postoperative cognitive dysfunction and other complications. Regional techniques can provide effective pain control with fewer systemic effects, thereby decreasing the likelihood of adverse drug reactions and interactions common in polypharmacy.

The selection of anesthetic agents is equally important, requiring careful dosing due to altered pharmacokinetics and pharmacodynamics in geriatric patients. Agents with shorter half-lives and fewer side effects are preferable. Minimizing the use of sedatives and opioids is critical to avoid exacerbating cognitive and respiratory issues, with multimodal analgesia offering a safer alternative. 

Monitoring and maintaining physiological stability during surgery is essential, as older adults are more susceptible to hemodynamic fluctuations. Personalized postoperative care plans, including tailored pain management and enhanced recovery protocols, facilitate early mobilization and improve functional outcomes. 

Interdisciplinary collaboration among anesthesiologists, surgeons, geriatricians, and other healthcare professionals is vital to ensure comprehensive and continuous care, ultimately improving surgical outcomes and quality of life for elderly patients.

The importance of Enhanced Recovery Protocols (ERPs)

Enhanced Recovery Protocols (ERPs) for geriatric patients are designed to improve surgical outcomes and expedite recovery by implementing evidence-based practices that address the unique challenges faced by older adults. These protocols aim to minimize the physiological stress of surgery, reduce complications, and promote early return to normal function through a comprehensive, patient-centered approach.

  • Multimodal pain management: This involves combining analgesics and techniques to minimize reliance on opioids, avoid significant effects, and employing non-opoid medications, regional anesthesia, and local anesthesia when appropriate.
  • Early mobilization: Encouraging movement soon after surgery improves muscle strength and improves circulation. Often, early mobilization includes physical therapy and supervised exercise programs that are tailored to the patient’s capabilities. Early mobilization can prevent complications such as deep vein thrombosis, pneumonia, and muscle atrophy.
  • Nutritional Support: This aspect of patient care ensures the individual has adequate nutrition before and after surgery for wound healing and immune function. Often, this includes preoperative nutritional assessments and provide postoperative high-protein, calorie-rich diets to address deficiencies and reduce complications.
  • Fluid Management: Medical teams must ensure patients maintain proper hydration without causing fluid overload, which involves using tailored strategies to ensure hemodynamic stability and support organ function.
  • Interdisciplinary Collaboration: A holistic approach to patient care before and after surgery involves anesthesiologists, surgeons, geriatricians, nurses, physical therapists, nutritionists, and other healthcare professionals. Collaboration between these teams is vital to ensure comprehensive and continuous care with timely interventions through a team-based approach.

Ensuring safe and effective anesthesia for the aging population

By implementing strategies like comprehensive geriatric assessments, tailored anesthetic approaches, enhanced recovery protocols, and interdisciplinary collaboration, healthcare providers can ensure safer surgical experiences and better postoperative outcomes for elderly patients. Continuous improvement in geriatric anesthesia practices is essential to meet the growing needs of this vulnerable population. For professional anesthesia management services, contact Valley Regional Anesthesia Associates (VRAA) today.