Anesthesia and the Elderly Patient

Sheila R Barnett, MDAssistant Professor

AnesthesiologyHarvard Medical School

Beth Israel Deaconess Medical Center

Population

USA

> 65y

>85 y

Surgery > 65 years

Frequency of 12 common procedures

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800

<15 y 15-44 y 45-64 y >65 y

Su

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35% of surgeries in USA

16,000,000 surgeries per year

RISK & COMORBIDITIES

Aging involves physiological changes

AND

the pathophysiology of superimposed disease

30 day Surgical Mortality

2nd Qtr 3rd Qtr 4th Qtr27.4 90 20.438.6 34.6 31.646.9 45 43.9

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1

2

34

5

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910

30 Day Percent mortality

All ages60 -69y70-79y>80y >90 y

Thoracotomy mortality over 70y: 17% Emergency abdominal surgery > 80y: 10%Major procedure mortality over 90y: 20 %

Jin & Chung Br J Anaesth 2001; 87:604-24

Present later Review of colorectal surgery Outcomes 65-74; 75-84; >85 years 34 194 patients Oldest patients:

Presented later More co morbidities Emergency more common Survival lower

Lancet 2000; 356: 968

Preoperative conditions

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544 patients > 70 y. JAGS 2001 49:1080

%

344 high risk CEA patients, mean 72 y. NEJM 2004; 351:1493

Surgery Outcomes

> 70y non cardiac surgery ; prospective 544 patients – age 78y 21% adverse outcome

3.7 % died Adverse outcomes:

CVS 10% CNS 8% Pulmonary 5.5% Renal 2.5% LOS: 9 vs 4 days (p<0.001)

Predictors: Emergency ASA Class

Tachycardia

Preop : Functional status CHF

Leung et al JAGS 2001 49:1080

Long term impact

Follow up 28 months on 517 patients - 32% deceased

With complications: greater 3 month mortality (p 0.02)

Predictors of mortality (p<0.0001) Cancer, ASA>2, CNS disease, Age, & Postop pulmonary and renal complications

Long term quality of life Not impacted by postoperative outcome comorbid conditions, age and new hospitalizations

Manku & Leung Anesth Analg 2003;96:583 -94 (pts 1&2)

80 year old patients 26 648 > 80 y compared to 568 263 < 80 y

30 day mortality all cases 8% vs. 3%, p<0.001 < 2% > 80 y for simple procedures

TURP, IH, TKR, CEA > 80y 20% 1 or more complications 26% mortality in patients > 80 y with

complications vs. 4% if no complication Mortality if > 80y with serious complications >

33%

Hamel et al JAGS 2005; 53:424

General Risk Factors for post operative mortality ASA 3 & 4 Major surgical procedures Disease: Cardiac, pulmonary, DM,

Liver and renal impairment Functional status < 1-4METS Anemia & Low albumin Bed ridden

Pathophysiology of Aging

Cardiovascular Peripheral

Decrease in arterial elasticity – vascular stiffening

Increase in BP Increase peripheral vascular resistance

Ventricular Increased impedance - wall hypertrophy decreased compliance Resting CO unchanged more atrial dependence

Cardiovascular Rate & Rhythm

Conduction issues: Decline in pacemaker

cells, fatty infiltration, fibrosis

Increase in atrial ectopy, sinus and

ventricular conduction defects

Reduction in maximal HR – reduced

response to catecholamines

Increased ischemic heart disease

Cardiovascular Autonomic Function Dysautonomia of Aging

Decline in beta receptor sensitivity HR responses impaired

Increased norepinephrine levels

Altered sympathovagal balance - decreased HRV

Decreased baroreflex sensitivity

Heart Failure

6-10% > 65 heart failure

80% admissions with heart failure are >65 y

40 –50 % of patients with heart failure have normal LVEF

Diastolic Dysfunction

Diastolic Function

Classification

% LVEF

Normal 37% 54%

Mild to Moderate

57.9% 54.5%

Moderate 3.9% 54%

Severe 1.7% 43%Philip Anesth Analg 2003 ; 97 1214-21

251 patients / CAD Age 72 y

Diastolic function : E/A & deceleration time

61.5%

HTN Prevalence

WOMEN

MEN

Hypertension > 50% elderly

Treatment usually > 140/90 mmHg “High normal” 130-139/85-89

mmHg

VA study – Berlowitz NEJM 1998;339:1957

800 males aged 65+/- 9years 40% BP > 160/90 mmHg Despite 6 visits /year

NHANES lll only 29% hypertensive population reach target goal

Complications of HTN

Risk increases linearly with BP“High normal” BP 130-139 / 85-89 mmHg

also increased risk Ischemic heart disease & MI Stroke LVH Diastolic dysfunction & pulmonary

edema Renal failure

Increased Pulse Pressure

Pulse pressure = SBP –DBP

? Possible marker for vascular disease

Low DBP also poor prognosis

Framingham Heart Study1924 men & women Ages 50-79yBP components & CHD risk 20 y f/u

Franklin et al Circulation 1999; 100: 354

CHD risk increased when SBP > 120 and DBP decreased

The ll/VI SEM

Aortic Sclerosis - is it really benign?

>5000 echos 29% (1600) with sclerosis, no

obstruction 5 year f/u

Almost 50% increase in death from CVS causes and MI in sclerosis

Otto et al, NEJM 1999

Pulmonary Function and Aging

Thorax stiffens – reduced chest wall compliance &

decreased thoracic skeletal muscle mass = Increased work of maximal breathing

Lung volumes change – reduced inspiratory and expiratory reserve volume

Decrease in elastic lung recoil –closing volume increase

Aspiration Risk

Reduction pharyngeal sensation

Reduction of maximal NIP

Swallowing coordination may be diminished

Central Nervous System

Cortical grey matter attrition – starts in middle age

Cerebral atrophy – disease vs. aging

Increased intracranial CSF

CBF and auto regulation largely maintained

CNS deficiencies Neurotransmitter deficiencies Integration of neuronal circuits Fluid intelligence

Spinal cord demyelination Decreased spinal reflexes

Peripheral nervous system Fibrosis in peripheral nerves

Less myelinated fibers

Slower nerve conduction

Diminished muscle mass

CNS & Drugs Pharmacodynamic MAC Altered respiratory drive & drugs

Spinal drugs Epidural spread sensitivity

Cognitive Dysfunction Post operative delirium

Cognitive dysfunction:non-cardiac surgery

Post cardiac surgery

Post-operative delirium

Incidence 10-15% in >65y

Increased mortality Longer hospital stay Numerous risk

factors: Advanced age Dementia, Depression Anemia

Alcohol and drug withdrawal Metabolic derangement Acute MI Infection Emergency surgery

Delirium costs! Per year over 2.3 million older

people have delirium during hospital stay

17.5 million inpatient days

>$ 4 billion (1994 #s) Medicare expenditure

Inoye NEJM 1999; 340:669

1218 patients >60 years Early 7 days 26% Late 3 months 9.9% (controls 2.8%)

Early Increasing Age Duration anesthesia Low education Second operation Infections Respiratory Complications

Late Age only

Moller et al Lancet 1998

Postoperative Cognitive Dysfunction

RCT: 262 patients Knee replacement – epidural vs. general 5% clinical deterioration in cognitive

status at 6 months No difference GA vs. regional Early delirium may be marker for ongoing

cognitive deterioration

Many similar trials and results …(but fractures & joint replacements – apples and oranges?)

Williams Russo et al JAMA 1995; 274:44

Is it the Anesthetic?

Confusion – what can you do?

Quick baseline assessment – date, year etc

Days of the week backwards Honest informed consent to patient and

family members Careful drug (and ETOH) history Avoid polypharmacy Pain control

Mild Cognitive Impairment “Transitional state between the cognitive

changes of normal aging and the earliest clinical features of Alzheimer's disease”

10 -15% will develop Alzheimer's in a year

1-2% normal elderly – Alzheimer’s

Role of genetics and Apolipoprotein E 4 alleles

Petersen et al NEJM 2005; 352:2379

Vascular patients

Longitudinal study – 11 years 4141 men & 1681 women Cognitive testing Poor cognitive function

Independent of age or SE class Angina p 0.001 MI p 0.02 Claudication p.004

Singh-Manoux JAGS 2003; 51:1445

Should we do more? Informed Consent ?

Hospitalization “unmask” marginal cognitive function

Dementia prevalent

Postoperative rehabilitation plans

Cognitive Preoperative Assessments?

Renal Function

Progressive decrease in Renal Blood flow

Renal tissue atrophy - primarily cortical 30% reduction in nephrons age by middle

age Sclerosis reaming nephrons

Glomerular filtration rate declines

Serum creatinine misleading – ‘occult’ renal insufficiency

Fluid homeostasis Sodium conservation impaired Urine concentrating ability reduced Thirst diminished

Post operative Acute Renal Failure >50% mortality in very elderly patients

Body Compartments

Decline in total body water intracellular water plasma volume maintained

Less lean tissue & skeletal muscle mass

Increase proportion of fat

Hepatic Decrease in hepatic mass

Decrease in hepatic clearance

Less albumin

Qualitative change in protein binding

Alpha-1-glycoprotein increases

Drug considerations water soluble drugs

prolonged half life of lipophilic drugs

decreased hepatic metabolism& renal clearance

increased target organ sensitivity

Risk – What Dose?

Summary pathophysiology

Steady decline in organ function

Unpredictable reserve function

Increased comorbidity

Reserve Function Diminished

Risk Reduction Beta Blockade Comprehensive assessments Less invasive surgery ? Regional

Beta Blockade & Risk Reduction

Mangano NEJM 1996;335:1713

100/200 patients received Atenolol preop and for 7 days

Atenolol group improved survival 6 months & up to 2 y. Diabetes major risk

Wallace Anesth 1998;88:7

Atenolol reduced postoperative ischemia by 30- 50%

High risk vascular patients with positive dobutamine echocardiograhpy. Mean age 68y 173/ 846 positive echos

59 bisoprolol 61 excluded on Beta blockers /wma 53 standard care (SC)

Bisoprolol vs SC death or non fatal MI:

2 (3.4%) vs 18 (34%) Poldermans NEJM 1999;341:1789

Beta blockers continued …

> 600 000 patients undergoing non cardiac surgery

18% received perioperative beta blockade

Reduction in death for those with a Cardiac Risk Index Score of 2-4

But possible increased risk of death for those with Cardiac Risk Index of 0 or 1

Lindenauer et al NEJM 2005; 353:349

Beta Blocker Prescription after AMI by Age

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45,370 patients eligible for beta blockade

Vitagliano et al. JAGS 2004: 52:495

Beta Blockers & the Frail

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Frailty Stage

Vitagliano et al. JAGS 2004: 52:495

Comprehensive Geriatric Assessments (CGA)

120 patients >60 y CGA

ADLs, IADLs (Barhtel Index) , comorbidity, nutrition, MMSE

All undergoing thoracic surgery 17% post op complications Predictors –

Low Barthel Index Surgery >300 mins Dementia – low MMSE

Fukuse Chest 2005; 127:886

Intervention Program to Reduce Delirium 400 patients > 70 y Admitted to Intervention Ward

Assessment, prevention treatment education Assessment day 1,3,7 Delirious patients in the Intervention ward

Shorter duration: by day 7 30% vs 60% (p 0.001 ) Shorter LOS: 9 vs 13 days (p 0.001) Reduced mortality: 2 vs. 9 patients died (p 0.03)

Lundstrom et al JAGS 2005:53:622

Less invasive surgery ? CEA

344 high risk patients average 72 y Stent vs. open Results showed stent as good –

possible reduction in death at 1 year and at least as good or less adverse events

Endovascular AAA 1 year perioperative survival advantage

vs. open

Yadav et al NEJM 2004; 351:1493

Blankenstein et al NEJM 2005; 352:2398

Spinal or Epidural vs. General Anesthesia

Long a source of controversy Expert opinion suggesting no significant

difference in major complications or mortality

Meta-analysis of 141 randomized trials Total of 9559 patients Studied neuraxial blockade (either spinal

or epidural anesthesia) vs. general anesthesia

BMJ 2000;321:1

Rodgers et al BMJ 2000; 321:1-12

Meta-Analysis of Neuraxial Blockade vs. General Anesthesia

Perioperative event Odds reduction for

neuraxial blockade

Death 30%

DVT 44%

Pulmonary embolism 55%

Pneumonia 39%

Respiratory depression

59%

Myocardial infarction 33%

Rodgers et al BMJ 2000; 321:1-12

Fractures too… Meta analysis 15 randomized trials 2162

patients In Spinal:

Reduction in 1 month mortality (6% vs 9%)

Reduction in DVT

Future – epidural vs LMWH and other anticoagulant strategies

Urwin et al Br J Anesth 2000; 84(4) 450-455

Cataracts

Low risk High volume High comorbidity

Do you ever wonder why we are in the room?

1999 Survey in USA 45% Ophthalmologists using topical

Rosenfeld in 1999 1006 patients 33% needed an intervention during surgery No predictive factors

International Studies 78% anesthesiologist present But low topical rate

Reeves survey ‘net preference’ for anesthesiologists

Stein et al; NEJM 2000; 342: 168

Routine Preoperative Testing before CataractSurgery

R o utine T e sting 9 4 08 P a tie n ts

N o T e sting9 4 11 P a tie n ts

1 8 1 8 9 C ata rac t p a tie n ts

Preoperative Medical Assessment

No tests unless new or worsening condition

EKG; CBC; Lytes, BUN, Creat & Gluc

No Testing Routine Testing

Both groups intra and postoperative medical events 3.1/ 1000 operations

“Routine medical testing before cataract surgery does not measurably increase the safety of the surgery”

But… Preoperative evaluation done in ALL

patients and ALL patients had opportunity to have testing

Conclusion Testing should directed by history and

physical performed prior to surgery

The Hip Fracture A Morbid Event

Is the hip fracture the sentinel event marking deterioration ?

Hip fractures 300 000 hospitalizations 1 year mortality 25% - reduction life

expectancy Attributable cost of fracture $81 300 Disability significant M & M US in 1997 > $20 Billion

Braithewaite JAGS 2003; 51: 364

Hip fractures, old people and the inevitable …..

Hip fractures have high perioperative mortality 10 -25%

Why? 300 unselected hip fractures All received similar multimodal

treatment Anesthesia epidural / strict protocol Well defined rehabilitation

Foss & Kehlet 2005; Br J Anaesth 94; 24-9

30 day mortality =13% ; >30 days 7 more died

Combined mortality=16%

Analysis of 47 deaths 28% (13) unavoidable: terminal cancer, refused

care 15% (7) probably unavoidable 34% (16) potentially avoidable; active care

curtailed 23% (11) Maximum care; ? avoidable

Why did they die? Foss & Kehlet 2005; Br J Anaesth 94; 24-9

Miscellaneous

Sensory Changes Decreased visual acuity & dark adaptation

Attrition of taste buds

Diminished thirst sensation

Compromised joint perception

Diminished fine control of skeletal muscles

> 80y

DISABILITIES COMMON

Polypharmacy

Adverse drug events 3 -10% admissions common

Elderly on multiple medications 30% prescriptions & 40% of OTC

drugs

Drugs and herbs eg Ephedra alkaloids -ma huang Adverse Events : HTN, palpitations,

strokes, seizures

ETOH & Elderly Alcohol and Drug prescription problems

affect 17% of older Americans

Increase sensitivity & decrease in tolerance

Decrease lean body mass & TBW = higher concentration

Decrease in alcohol dehydrogenase may slow metabolism

Social Issues

Increase in disability

Lack of a spouse

Cognitive and sensory problem Scheduling - a family commitment

Challenges & Elderly

heterogeneous population

unpredictable organ reserve

disease burden

atypical disease presentation

emergent procedures

minor complications can rapidly

escalate

Geriatric Graphs

Age years Function

Age years

Disease or

badness

Future ? Cognitive Preoperative assessment

Functional outcomes

Perioperative interventions