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GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults. AGS

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Page 1: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

GERIATRIC ANESTHESIA:AN INTRODUCTION

Jeannette Lee, MDAnesthesiology Resident

Ruben J. Azocar, MD Associate Professor of

Anesthesiology

THE AMERICAN GERIATRICS SOCIETY

Geriatrics Health Professionals.

Leading change. Improving care for older adults.

AGS

Page 2: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

OBJECTIVES

• Review the ongoing demographic changes in the elderly segment of the population

• Analyze the impact of the growing geriatric populations in health care

• Summarize the most important physiologic changes that occur with aging

Slide 2

Page 3: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

ELDERLY POPULATION

• “Elderly” is defined as >65 years old

• “Very old” is defined as >85 years old

• The elderly population currently comprises 12% of the US population

Projected to increase to 20% by 2040

Slide 3

Page 4: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

ELDERLY POPULATION IN THE US

Slide 4

Page 5: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

ELDERLY POPULATION IN THE US

Slide 5

Page 6: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

THE ELDERLY AS A PROPORTIONOF THE US POPULATION

Slide 6

Page 7: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

GLOBAL ELDERLY POPULATION

• In 2000 the global population >65 years old was estimated to be 420 million

• It is projected that by 2010, the elderly population will increase 847,000 per month

Slide 7http://www.census.gov/prod/2001pubs/p95-01-1.pdf

Page 8: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

GLOBAL ELDERLY POPULATION

Slide 8

Page 9: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

PROCEDURES FOR THE ELDERLY

• From 19942005 the average number of inpatient procedures per year in patients >65 years old increased from 6,500,000 to 7,353,000

• Currently 35% of all surgical procedures are performed in elderly patients

• More than half of the elderly population will have at least one procedure done before they die

Slide 9www.cdc.gov/nchs/data/hus/hus07.pdf#102

Page 10: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

POSTOPERATIVE MORTALITYIN THE ELDERLY

Slide 10

• Monk et al reported a prospective observational study of 1064 patients undergoing noncardiac surgery

• > 65 yo had a 1-year mortality rate of 10.3% vs. 5.5% in all patients

• >65 yo had a relative risk of 1-year postoperative mortality of 4.459, which was the third highest risk factor, after having 3 or more comorbidities or an ASA of 3 or 4.

Monk TG et al. Anesth Analg. 2005;100:4-10.

Page 11: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

PHYSIOLOGIC CHANGES WITH AGING

• Functional and structural changes occur in most organ systems

• Although the basal function may remain stable in various organs systems, the functional reserve and the ability to compensate under physiologic stress are greatly reduced

Slide 11

Page 12: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

PHYSIOLOGIC CHANGES WITH AGING: BODY COMPOSITION

• Skeletal muscle mass decreased

• Percentage of body fat increased

• Total body water decreasedWater-soluble drugs: reduced volume of distributionLipid-soluble drugs: increased volume of distribution

• DO2 and heat production decreased

Slide 12

Page 13: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

PHYSIOLOGIC CHANGES WITH AGING:CENTRAL NERVOUS SYSTEM

• Brain mass decreases, mainly from loss of neural tissue

• 10%20% reduction in cerebral blood flow

• Decreased number of serotonin, acetylcholine, and dopamine receptors

• Decline in memory, reasoning, perception

• Disturbed sleep/wake cycle

Slide 13

Page 14: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

PHYSIOLOGIC CHANGES WITH AGING:CARDIOVASCULAR SYSTEM

• LV hypertrophy and decreased compliance

• Increase in vascular rigidity Decreased compliance of venous vessels

• Desensitization of β-adrenergic receptors Decreased PNS tone and increased SNS tone

• SVR and SBP increased

• SV and CO decreased

• Diastolic LV dysfunction

• Decreased maximally attainable HR

Slide 14

Page 15: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

PHYSIOLOGIC CHANGES WITH AGING:PULMONARY SYSTEM

• ↑ Central airway size and ↓ small airway diameter no change in airway resistance

• ↓ Functional alveolar surface area

• ↓ Gas exchange ↓ PaO2 and ↑ Aa gradient

• ↑ Lung compliance and RV leads to ↑ FRC• No changes in TLC

Result is ↑ RV/TLC and FRC/TLC ratios

Slide 15

Page 16: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

PHYSIOLOGIC CHANGES WITH AGING:PULMONARY SYSTEM

Decrease Increase• Respiratory muscle strength • Chest wall height• Respiratory center sensitivity• Chest wall compliance• Effective cough and swallow ↑

aspiration risk

• DLCO2

• PIMAX and PEMAX

• ERV and VC• FVC, FEV1, FEV1/VC, and FEF

at low lung volumes

• Chest wall stiffness• AP diameter• Closing volume and closing

capacity

Slide 16

Page 17: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

PHYSIOLOGIC CHANGES WITH AGING:RENAL SYSTEM

• Tissue mass decreased

• Perfusion decreased

• GFR decreased

• Reduced ability to dilute and concentrate urine and conserve sodium

• Drug clearance decreased

Slide 17

Page 18: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

PHYSIOLOGIC CHANGES WITH AGING:HEPATIC SYSTEM

• Tissue mass decreased

• Blood flow decreased

• Possible decrease in affinity for substrate

• Possible decrease in intrinsic activity

• Decreased first-pass metabolism of some drugs

Slide 18

Page 19: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

PHYSIOLOGIC CHANGES WITH AGING: ENDOCRINE CHANGES

• ↓ ADH response to hypovolemia and hypotension

• ↓ Renin and aldosterone leads to ↓ response to sodium restriction and postural changes are blunted

• No changes in adrenocorticotropic hormone, cortisol, catecholamine production in adrenal medulla, or TSH

• Insulin release is impaired Impaired peripheral tissue resistance and decreased

clearance leads to ↑ plasma insulin levels and ↑ fat deposits

Slide 19

Page 20: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

PHYSIOLOGIC CHANGES WITH AGING:PK AND PD ISSUES

• Protein binding ↓ Level of proteins Multiple medications interfere with drug binding sites ↑ Level of free unbound drug in plasma prolonged effect

• ↓ Lean and ↑ fat body mass ↑ Storage of lipid-soluble drugs prolonged effect and longer

time for elimination

• ↓ Circulating blood volume ↑ Initial plasma drug concentration

Slide 20

Page 21: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

CONCLUSIONS

• The proportion of older individuals in the US population continues to rise

• Many of them will require surgery and anesthesia

• Physiologic changes of age have a great impact in the perioperative period

Slide 21

Page 22: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

ACKNOWLEDGMENTS

• Supported by a grant from the Geriatric Education for Specialty Residents Program (GS), which is administered by the American Geriatrics Society and funded by the John A. Hartford Foundation of New York City

• Our gratitude to Dr. Alec Rooke for his assistance with many of these slides

Slide 22

Page 23: GERIATRIC ANESTHESIA: AN INTRODUCTION Jeannette Lee, MD Anesthesiology Resident Ruben J. Azocar, MD Associate Professor of Anesthesiology THE AMERICAN

Visit us at:

Facebook.com/AmericanGeriatricsSociety

Twitter.com/AmerGeriatrics

www.americangeriatrics.org

THANK YOU FOR YOUR TIME!

linkedin.com/company/american-geriatrics-society

Slide 23


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