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recommended; similarly long acting benzodiazepines can
accumulate in the older patient and should be avoided.
In contrast to delirium, POCD refers to a specific cognitive disorder generally recognized in the postoperative period
and is ultimately diagnosed through neuropsychological
testing. Studies have demonstrated that almost 10% of elderly
patients receiving a general anesthesia had some cognitive
dysfunction 3 months after surgery. The cause of POCD is
unknown, and multiple studies have looked at the difference
in prevalence between general and regional techniques
[44, 47, 48]. To date there is no convincing evidence that
regional anesthesia offers any cognitive advantages over
general anesthesia.
The Intraoperative Course
Monitoring
Basic monitoring standards for all patients, including the
elderly, undergoing anesthesia have been established by the
ASA. The first standard requires the continuous presence of
qualified anesthesia personnel in the operating room. The
second standard requires a continuous assessment of the
patient’s oxygenation, ventilation, circulation, and temperature. Although these standards are not different for older
patients, aging patients may have associated comorbid conditions that influence monitoring choices.
In most instances, oxygenation is continuously assessed
using variable pitch pulse tone pulse oximetry. As a fall in
oxygenation may actually be a late indicator of hypoventilation, ventilation should be monitored using end tidal carbon
dioxide to provide early identification of hypoventilation and
possible hypercapnia. In addition to continuous ECG monitoring, the ASA requires BP assessment at least every 5 min.
The decision to use additional invasive monitoring depends
on the patient and the procedure. In the older patient labile
blood pressure is commonly encountered [49], and a low
threshold for continuous arterial blood pressure monitoring
should be maintained. An arterial line can assist in both the
precise titration of medications and access for blood sampling during the case.
Aging cardiac changes render the older patient more
susceptible to congestive heart failure in the event of excessive fluid administration or significant shifts in volume [3,
50]. Central monitoring of the central venous pressure or
pulmonary artery catheter may be useful to manage the fluid
administration during a case. Interpretation of the central
pressure requires a careful consideration of the aging patients
underlying physiologic condition. For instance, an older
hypertensive patient with a “normal” CVP may actually be
modestly hypovolemic. In general, elderly patients benefit
from higher preloads and are very dependent on the atrial
contraction during diastole. There is significant controversy
over the utility of the PA catheter as a tool to measure volume
status and guide fluid resuscitation and the role of the
transesophageal echocardiogram is yet to be established.
The Surgery
Laparoscopic surgery carries significant advantages in the
elderly patient including a more rapid recovery, less pain following surgery, and reduced fluid requirements [51–53].
Laparoscopic cholecystectomy has been associated with
improved postoperative pulmonary function vs. open cholecystectomy, and that may be advantageous for the frail elder
with reduced pulmonary reserve. General anesthesia with
controlled ventilation is preferred to allow adequate abdominal insufflation. During the surgery absorption of CO2 can
result in hypercapnia and acidosis. The rise in intra-abdominal pressure accompanying the insufflation can lead to
reduced venous return, increased peripheral resistance, and
intrathoracic pressure leading to a diminished cardiac output
and hypotension. In the frail elderly patient with reduced
cardiac function these cardiovascular challenges can be significant, requiring increased monitoring, and adjustment of
the anesthetic medications to optimize cardiac function.
Medications
A decrease in total body water and increase in adipose can
lead to a change in distribution of medications. Specifically,
the water soluble agents such as most induction agents are
distributed in a smaller initial compartment, resulting in
increased exposure of receptors and potentially augmented
impact. In contrast, lipid soluble medications may be deposited in larger fat stores leading to prolonged and unpredictable
recovery. Age-related hepatic changes and reduction in hepatic
blood flow can result in a delay in the metabolism of certain
drugs such as lidocaine [54]. Although albumin levels are
usually preserved in health, they may be diminished in older
patients with chronic disease, in general, the quality of protein
binding may be reduced and these combined changes can lead
to increased free fractions of tightly bound medication such as
warfarin. For certain drugs such as the benzodiazepines and
opioids, [55–57] age related increased sensitivity seems more
related to changes in the pharmacodynamic and sensitivity of
the receptors as opposed to an alteration in the distribution or
clearance of the medications. In the next section, the impact
of aging on individual agents will be considered [40].
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Anxiolytics
Benzodiazepines provide anxyiolyisis and amnesia.
Diazepam and lorazepam are long acting anyxioltics com-
pared with midazolam, and their administration has been
associated with postoperative delirium. In general, these longer acting drugs should be avoided in frail geriatric patients,
although lorazepam may be indicated in certain circumstances such as alcohol withdrawal [56, 58].
Midazolam is a water soluble benzodiazepine generally
given intravenously as an anxiolytic prior to the induction of
anesthesia or as an adjunct to sedation; it may even be used
as the sole anesthetic agent for very brief procedures. It is
metabolized via hepatic hydroxylation to its major metabolite 1-hydroxymidazolam that is subsequently conjugated
and excreted. Pharmacodynamic changes with aging result
in increased sensitivity to midazolam and the starting dose
should be reduced to 0.5–1 mg, and increased slowly if
needed [56]. There are very limited hemodynamic effects,
although hypotension has been observed when midazolam is
combined with fentanyl. In general, in older patients, it is
advantageous to avoid midazolam altogether, and if needed
in anxious patients the initial and subsequent doses should be
reduced.
Etomidate is another induction agent frequently used to
induce anesthesia, especially in elderly patients, trauma victims, or emergency circumstances. In contrast to propofol,
etomidate has almost no cardiovascular side effects and is
preferred in the patient with unstable hemodynamics and
poor cardiac reserve. In older patients with significant cardiac disease or unknown physiological reserve etomidate
can be advantageous. In general, the induction dose should
be reduced 25–50% in elderly patients.
Ketamine is a phencyclidine derivative, NMDA blocker that
can produce dissociative anesthesia. Advantages of ketamine
include absence of respiratory depression and analgesic
properties. In the elderly patient, small doses of ketamine
can reduce opioid requirements and offset the hypotensive
effects of higher propofol doses during an MAC anesthetic.
Its use has been associated with bad dreams and agitation in
younger patients, but this may be less of a problem in the
older patient when administered with low dose benzodiazepines or propofol. Preemptive low dose ketamine infusions
in the postoperative period have been used to treat patients
with significant pain that is resistant to traditional medications.
The opioid sparing effects of ketamine can be very useful in
the older compromised patient. At these lower doses, there
has been no evidence of any increase in cognitive problems.
Induction Agents
Propofol or 2,6 di-isopropyl phenol is now the most
commonly used intravenous anesthesia agent inside the
operating room and also for procedures in remote locations.
Propofol provides excellent hypnosis, a rapid recovery, and
some protection against nausea and vomiting. Propofol also
causes significant vasodilatation and potential hypotension
that is exaggerated in older patients especially in the presence of hypovolemia. In general, older patients require less
drug (20–60% reduction) to achieve the same level of anesthesia. The initial propofol dose in the older patient is distributed in a smaller central volume of distribution, and the
peak concentration may be more pronounced and prolonged
compared with a young patient in whom the redistribution
occurs rapidly after the bolus dose. This translates to an
increased sensitivity of older patients to smaller bolus doses
and a delay to peak effect, including delayed peripheral
vasodilatation. Thus in the elderly patients, it is important
to reduce the bolus and increase the interval between
repeated doses. Administration of even a small dose of
propofol may result in respiratory arrest and for that reason
it has been recommended that its use is limited to anesthesiologists or providers trained in basic airway management
and resuscitation [40, 59].
Opioids
Elderly patient’s exhibit increased sensitivity to central respiratory effects of opioid medications, and this may lead to an
increase in the risk of unrecognized postoperative hypoventilation and apnea. In general, all initial opioid doses should
be reduced in older patients and careful monitoring of both
oxygenation and ventilation is required [60, 61].
Fentanyl is a synthetic opioid, about 50–100 times as potent
as morphine but not associated with histamine release. It is
lipid soluble and has a rapid onset with little effect hemodynamically and relatively short duration. During induction of
anesthesia, fentanyl has been shown to block the adverse
hemodynamic effects of intubation [
Remifentanil is another highly potent synthetic opioid that is
becoming increasingly popular for short stimulating procedures and sedation, especially in elderly patients in whom
significant perturbations of the cardiovascular system can be
deleterious. Remifentanil is metabolized by rapid hydrolysis
through esterases in blood and tissue, and is suitable for infusions. In older patients, the initial dose and infusion should
be reduced by about 33%. When larger doses are administered bradycardia (that can be profound) and respiratory
depression may occur and limit remifentnil’s use [57].
55, 62].
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Morphine is a popular opioid for postoperative pain [38, 61],
frequently administered via a PCA [63]. Older patients show
an increased sensitivity, decreased clearance, and in the presence of renal failure, the accumulation of metabolites can
occur. Several studies have suggested that the initial postoperative requirements of morphine are similar in old and young
patients but the maintenance doses should be reduced [64].
Meperidine is a short acting analgesic, which is not recommended in elderly patients. It has been associated with delirium and the accumulation of the metabolite normeperidine
that can be neuroexcitatory and lead to seizures.
Neuromuscular Blocking Agents
Muscle relaxation during surgery is critical for exposure and
to prevent patient movement, and is generally achieved
through the administration of nondepolarizing drugs such as
vecuronium and cisatracurium. These drugs are competitive
antagonists of acetylcholine at the nicotinic receptor and
act at the postjunctional membrane of the neuromuscular
junction. The most important anesthetic concern for the
elderly patients is the complete reversal of these agents at the
end of the surgery. Even a small amount of residual drug
effect could result in significant respiratory impairment in
the recovery room. For this reason, the longer acting muscle
relaxant pancuronium should be avoided altogether in older
patients.
Inhalational Agents
General anesthesia usually includes the addition of a volatile
anesthetic agent; the most popular agents include sevoflorane, desflorane, and isoflorane. It is well documented that
older patients require less volatile anesthetic to attain a suitable depth of anesthesia. The amount of inhalational agent
decreases linearly with aging so by age of 80 years a patient
requires only about one-third that needed in a 20-year-old
patient [
65].
Other
Dexmetatomidine is an alpha 2 agonist, similar to clonidine,
that is approved for sedation and has gained popularity as a
sedative and anesthetic adjunct. Dexmetatomidine has powerful analgesic properties and can be used in small bolus or
as a continuous infusion. In addition to providing sedation
and analgesia, dexmetatomidine is also a hemodynamic
depressant and its administration can cause significant
hypotension and bradycardia. In general, the cardiovascular
side effects limits the use in older patients with cardiac disease, but in certain cases such as plastics, the hypotensive
effect may be valuable; offsetting the hypertensive effects of
infiltration of local anesthesia that includes epinephrine [
The full extent of dexmetatomidine’s role in postoperative
analgesia has yet to be established.
Acetominophen is frequently overlooked as a useful opioid
sparing analgesic in the immediate post-recovery phase. For
the older patient without liver impairment, scheduled dosing is recommended and frequently combined with a multimodal approach that includes low doses of NSAIDs or
opioids [66].
Ketorolac is a potent NSAID available for intravenous
administration. It can be a useful adjunct for pain relief and
result in significant opioid sparing. Ketorolac, like all
NSAIDS, must be used cautiously in elderly patents, especially in patients with dehydration or renal failure, a history
of gastrointestinal bleeding, or anticoagulant or antiplatelet
therapy. Postoperatively ketorolac should be administered
for a short duration less than 5 days, and in older patients the
dose should be reduced 50% starting at 15
exceeding total 60 mg/24 h.
Gabapentin is an anticonvulsant that has strong analgesic
effects [67]. The mechanism of action of gabapentin is not
fully known, but probably involves the neurotransmitter
gamma amino butyric acid (GABA) system. Single preoperative doses of gabapentin have been found to reduce pain
intensity and opioid use in the first 24 h postoperatively. In
addition, gabapentin administration is associated with a
reduced incidence of postoperative nausea and vomiting,
constipation, and urinary retention, although an increase in
sedation has been noted, especially at higher doses.
mg and not
59].
Ambulatory Surgery
Older age is not a contraindication to ambulatory surgery.
Indeed some studies have suggested elderly patients may be
more able to be fast tracked through the recovery area and
discharged, possibly due to a reduction in medications and a
lighter level of sedation administered compared with young
healthy patients [51]. In general, there is limited data on
outcomes in older patients following surgery, however,
there is the suggestion that intraoperative arrhythmias and
hypertension are more common in older patients vs. younger
and that the incidence of postoperative nausea may be
diminished with age [7, 9]. Postoperative urinary retention
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CASE STUDY: PART 5
After discussion among the anesthesiologist, the endoscopist, and the patient, a general anesthesia is agreed
upon. Due to his high risk from aspiration and increased
risk of significant complications in the event of an aspiration, the anesthesiologist proceeds with a general anesthesia and endotracheal intubation. The endoscopist is
able to dilate his biliary duct at the time of the ERCP.
During the procedure, Mr. Smith receives several boluses
of phenylephrine for low blood pressure, but overall is
hemodynamically stable and extubated at the end of the
can lead to significant morbidity, for instance in older males
following hernia repair. In general, urinary retention has
been associated with the administration of opioids, regional
anesthesia (spinal or epidural anesthetics), male sex, older
age, and anticholinergic medications.
case. Mr. Smith’s Parkinson symptoms worsen temporarily
and mobility is a significant problem. After reinstating his
Parkinson medications, Mr. Smith is hospitalized for
4 days following the procedure. He is ultimately discharged home and his family notes that his memory
appears slightly worse, for instance, he has more trouble
with word finding, names, and dates than he did prior to
the surgery, but he does not appear delirious. This appears
to resolves over the next few months. His abdominal pain
is better following the dilation and the patient and the
family decline a laparoscopic cholecystectomy to remove
remaining gall stones.
of the operating room. Intraoperative heat loss may be
minimized by prewarming surfaces and maintain room temperatures high until the patient is fully draped. Warmed
forced air blankets have been associated with improved
maintenance of temperature.
Temperature Control
In general, exposure of a nonanesthetized patient to a cold
environment such as the operating room will result in activation of receptors peripherally and centrally that lead to vasoconstriction and an increase in heat production and basal
metabolic rate. Usually the core temperature is maintained a
few degrees higher than the peripheral tissues through tonic
vasoconstriction. Unfortunately, normal aging results in the
deterioration in thermoregulation both peripherally and centrally leading to an increased risk of hypothermia. The agerelated physiologic changes blunt vasoconstriction and heat
production, shivering is less effective and induced at lower
temperatures compared with younger subjects. Furthermore,
older patients have less lean body mass and lower basal
metabolic rates at the outset, and they lose heat more quickly
compared with younger patients.
The issues with temperature regulation are further exacerbated in the anesthetized elderly patient and the ability to
withstand cold temperatures is inhibited in the presence of all
anesthetic agents. Disordered temperature regulation has been
observed following both general and regional anesthetics.
The risks of hypothermia to an older patient are substantial
and include myocardial ischemia, surgical infection, coagulopathy, bleeding, delayed drug metabolism, and arousal [68].
Since older patients may not respond appropriately to a
drop in core temperature, the anesthetic plan should include
the ability to actively warm older patients in and outside
Summary
In summary, “choosing the best anesthetic” for the geriatric
patient requires meticulous attention to detail, knowledge of
the physiologic changes that can be expected to occur during
aging and an understanding of common comorbidities found
in the elderly population. The risk of anesthesia and surgery
is increased in frail older patients and anesthetics should be
designed to avoid side effects and eliminate the occurrence
of even small complications.
References
1. Leung JM, Dzankic S (2001) Relative importance of preoperative health
status versus intraoperative factors in predicting postoperative adverse
outcomes in surgical patients. J Am Geriatr Soc 49:1080–1085
2. Hosking MP, Warner MA, Lobdel CM et al (1989) Outcomes of surgery in patients 90 years of age and older. JAMA 261:1909–1915
3. Rooke GA (2003) Cardiovascular aging and anesthetic implications. J Cardiothorac Vasc Anesth 17:512–523
4. Kheterpal S, O’Reilly M, Englesbe MJ, Rosenberg AL, Shamks AM,
Zhang L, Rothman ED, Campbell DA, Tremper KK (2009) Preoperative
and intraoperative predictors of cardiac adverse events after general,
vascular and urological surgery. Anesthesiology 110:58–66
5. Cook DJ, Rooke GA (2003) Priorities in perioperative geriatrics.
Anesth Analg 96:1823–1836
6. Turrentine FE, Wang H, Simpson VB, Jones RS (2006) Surgical
risk factors, morbidity, and mortality in elderly patients. J Am Coll
Surg 203:865–877
318 S.R. Barnett
https://t.me/med1917
7. Pedersen T, Eliasen K, Henriksen E (1990) A prospective study of
mortality associated with anaesthesia and surgery: risk indicators of
mortality in hospital. Acta Anaesthesiol Scand 34(3):176–182
8. Manku K, Bacchetti P, Leung JM (2003) Prognostic significance of
postoperative in-hospital complications in elderly patients. I. Longterm survival. Anesth Analg 96:583–589
9. Chung F, Mezei G, Tong D (1999) Adverse events in ambulatory
surgery. A comparison between elderly and younger patients. Can J
Anaesth 46(4):309–321
10. Marick PE, Kaplan DL (2003) Aspiration pneumonia and dyspghagia in the elderly. Chest 124:328–336
11. Wang CY, Ling LC, Cardosa MS, Wong AKH, Wong NW (2000)
Hypoxia during upper gastrointestinal endoscopy with and without
sedation and the effect of pre-oxygenation on oxygen saturation.
Anaesthesia 55:654–658
12. Yano H, Iishi H, Tatsuta M et al (1998) Oxygen desaturation during
sedation for colonoscopy in elderly patients. Hepatogastroenterology
45:2138–2141
13. Hang J (2007) The controversy of regional vs. general anesthesia in
surgical outcomes. In: Seiber FE (ed) Geriatric anesthesia. McGraw
Hill, Philadelphia, pp 253–266
14. Urwin SC, Parker MJ, Griffiths R (2000) General versus regional
anaesthesia for hip fracture surgery: a meta-analysis of randomized
trials. Br J Anaesth 84(4):450
15. Williams-Russo P, Sharrock NE, Mattis S et al (1995) Cognitive
effects after epidural vs general anesthesia in older adults: a randomized trial. JAMA 274(1):44–50
16. Rasmussen LS, Johnson T, Kuipers HM et al (2003) Does anaesthesia cause postoperative cognitive dysfunction? A randomized study
of regional versus general anaesthesia in 438 elderly patients. Acta
Anaesthesiol Scand 47:260–266
17. Chung F, Meier R, Lautenschlager E et al (1987) General or spinal
anesthesia: which is better in the elderly? Anesthesiology 67:422–427
18. Simon MJG, Veering BT, Stienstra R et al (2002) The effects of age
on neural blockade and hemodynamic changes after epidural anesthesia with ropivicaine. Anesth Analg 94(5):1325–1330
19. Pitkanen M, Haapaniemi L, Tuominen M et al (1984) Influence of
age on spinal anaesthesia with isobaric 0.5% bupivicaine. Br J
Anaesth 56(3):279–284
20. Critchley LA (1996) Hypotension, subarachnoid block and the
elderly patient. Anaesthesia 51(12):1139–1143
21. Gustafsson LL, Schildt B, Jacobsen K (1982) Adverse effects of
extradural and intrathecal opiates: report of a nationwide survey in
Sweden. Br J Anaesth 54(5):479–486
22. Conference C (2003) Reg Anesth Pain Med 28:172–197
23. Roizen MF (1989) Preoperative patient evaluation. Can J Anaesth
36:513–551
24. Fischer SP (1996) Development and effectiveness of an anesthesia
preoperative evaluation clinic in a teaching hospital. Anesthesiology
85:196–206
25. Fleisher LA, Beckman JA, Brown KA et al (2007) AHA/ACC 2007
guidelines on perioperative cardiovascular evaluation and care for
non cardiac surgery. J Am Coll Cardiol 50:1701–1732
26. Roizen MF (1998) The compelling rationale for less preoperative
testing. Can J Anaesth 35:214–218
27. Bouillot JL et al (1996) Are routine preoperative chest radiographs
useful in general surgery? Eur J Surg 162:597–604
28. Schein OD, Katz J, Bass EB et al (2000) The value of routine
preoperative medical testing before cataract surgery. N Engl J Med
342:168–175
29. Narr BJ (1997) Outcomes of patients with no laboratory assessment
before anesthesia and a surgical procedure. Mayo Clin Proc
72:505–509
30. Starsnic MA, Guarnieri DM, Norris MC (1997) Efficacy and financial benefit of an anesthesiologist-directed University Preadmission
Evaluation Center. J Clin Anesth 9:299–305
31. Power LM, Thackray NM (1999) Reduction of preoperative investigations with the introduction of an anesthetist led preoperative
assessment clinic. Anaesth Intensive Care 27:481–488
32. ASA Task Force (2002) Practice advisory for preanesthesia evaluation. A report by the ASA Task Force on preanesthesia evaluation.
Anesthesiology 96:485–496
33. Gibb J, Cull W, Henderson W et al (1999) Preoperative serum albumin level as a predictor of operative mortality and morbidity. Arch
Surg 134:36–42
34. Gold BS (1992) The utility of preoperative electrocardiograms in
the ambulatory surgical patient. Arch Intern Med 152:301–305
35. Goldberger Al, OKonski M (1986) Utility of the routine electrocardiogram before surgery and on general hospital admission. Ann
Intern Med 105:552
36. ACC/AHA Guidelines (2007) ACC/AHA 2007 on perioperative
cardiovascular evaluation and care for noncardiac surgery. Circulation
116:e418–e500
37. Charpak Y et al (1998) Prospective assessment of a protocol for
selective ordering of preoperative chest x-rays. Can J Anaesth
35:259–264
38. Kalso E, Edwards JE, Moore RA, McQuay HJ (2004) Opioids in
chronic non-cancer pain: systematic review of efficacy and safety.
Pain 112(3):372–380
39. Zaugg M, Lucchinetti E (2000) Respiratory function in the elderly.
Anesthesiol Clin North America 18:47–58
40. Lortat-Jacob B, Sevrin F (2007) Pharmacology of intravenous drugs
in the elderly. In: Seiber FE (ed) Geriatric anesthesia, Ch 8. McGraw
Hill, New York, pp 91–105
41. Warner DO (2000) Preventing postoperative pulmonary complications. Anesthesiology 92:1467–1472
42. Novis BK et al (1994) Association of preoperative risk factors with
postoperative acute renal failure. Anesth Analg 78:143–149
43. Silverstein JH, Timberger BA, Reich DL, Uysal S (2007) Central
nervous system dysfunction after non cardiac surgery and anesthesia
in the elderly. Anesthesiology 106:622–628
44. Moller JT et al (1998) Long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study. Lancet 351:857–861
45. Okeefe ST et al (1994) Postoperative delirium in the elderly. Br J
Anaesth 73:673–687
46. Inouye SK (2006) Delirium in older persons. N Engl J Med
354(11):1157–1165
47. Williams-Russo P et al (1992) Post-operative delirium: predictors
and prognosis in elderly orthopedic patients. J Am Geriatr Soc
40:759–767
48. Dasgupta M, Dumbrell AC (2006) Preoperative risk assessment for
delirium after non cardiac surgery: a systematic review. J Am
Geriatr Soc 54:1578–1589
49. Reich DL, Hossain S, Krol M et al (2005) Predictors of hypotension after induction of general anesthesia. Anesth Analg 101:
622–628
50. Phillip B, Pastor D, Bellows W, Leung JM (2003) The prevalence of
preoperative diastolic filling abnormalities in geriatric surgical
patients. Anesth Analg 97:1214–1221
51. White PF, Kehlet H, Neal JM et al (2007) The role of the anesthesiologist in fast-track surgery: from multimodal analgesia to perioperative medical care. Anesth Analg 104:1380–1396
52. Hasuke S, Mesic D, Dizdarevic E, Keser D, Hadziselimovic S,
Bazardzanovic M (2002) Pulmonary function after lapraroscopic
and open cholecystectomy. Surg Endosc 16:163–165
53. Karayiannakis AJ, Makri GG, Mantzioka A, Karousos D, Karatzas G
(1996) Posoperative pulmonary function after laparoscopic and open
cholecystectomy. Br J Anaesth 77:448–452
54. Schucker DL (2005) Age related changes in liver structure and
function: implications for disease? Exp Gerontol 40:650–659
55. Singleton MA, Rosen JI, Fisher DM (1988) Pharmacokinetics of
fentanyl in the elderly. Br J Anaesth 60(6):619–622
31925 Choosing the Best Anesthetic Regimen
https://t.me/med1917
56. Jacobs R et al (1995) Aging increases pharmacodynamic sensitivity to the hypnotic effects of midazolam. Anesth Analg 80:
143–148
57. Minto CF, Schnider T, Egan T et al (1997) Influence of age and
gender on the pharmacokinetics and pharmacodynamics or remifentanil. Anesthesiology 86:10–23
58. Reidenberg MM, Levy M, Warner H et al (1978) Relationship
between diazepam dose, plasma level, age, and central nervous
system depression. Clin Pharmacol Ther 23:371–374
59. Arain SR, Ebert JE (2002) The efficacy, side effects, and recovery
characteristics of dexmedetomidine versus propofol when used for
intraoperative sedation. Anesth Analg 95:461–465
60. Cepeda MS, Farrar JT, Baumgarten M et al (2003) Side effects of
opioids during short-term administration: effect of age, gender, and
race. Clin Pharmacol Ther 74(2):102–112
61. Moore RA, McQuay HJ (2005) Prevalence of opioid adverse events
in chronic non-malignant pain: systematic review of randomized
trials of oral opioids. Arthritis Res Ther 7(5):R1046–R1051
62. Bentley JB, Borel JD, Nenad RE Jr et al (1987) Age and fentanyl
pharmacokinetics. Anesth Analg 61(12):968–971
63. Sessler DI, Sessler DI (2008) Perioperative thermoregulation. In:
Silverstein JH, Rooke GA, Reves JG, McLeskey CH (eds) Geriatric
anesthesiology, 2nd edn. Springer, New York, pp 107–122
64. Aubrun F (2005) Management of postoperative analgesia in elderly
patients. Reg Anesth Pain Med 30:363–379
65. Mapelson WW (1996) Effect of age on MAC in humans: a metaanalysis. Br J Anaesth 76:179–185
66. Remy C, Marret E, Bonnet F (2005) Effects of acetaminophen on
morphine side-effects and consumption after major surgery: metaanalysis of randomized controlled trials. Br J Anaesth 94(4):505–513
67. Ho KY, Gan TJ, Habib AS (2006) Gabapentin and postoperative
pain – a systematic review of randomized controlled trials. Pain
126(1–3):91–101
68. Gagliese L, Jackson M, Ritvo P, Wowk A, Katz J (2000) Age is not
an impediment to effective use of patient-controlled analgesia by
surgical patients. Anesthesiology 93(3):601–610
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Chapter 26
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Acute Postoperative Pain Management in Elderly Patients
Jack M. Berger
In their review article, Brennan, Carr, and Cousins conclude
that “because pain management is the subject of many initiatives within the disciplines of medicine, ethics, and law, we
are at an ‘inflection point’ in which unreasonable failure to
treat pain is viewed worldwide as poor medicine, unethical
practice, and an abrogation of a fundamental human right”
[1]. In coming to this conclusion these authors review much
of the medical ethics literature which taken together is summarized in their statement that “…a virtue ethics approach to
bioethics would also yield a clear response to patient’s pain.
A virtuous doctor would place the recognition, monitoring,
and treatment of pain as a high priority. To this end, a virtuous
doctor would inquire regularly about pain, respond appropriately, and refer wisely if unable to control it” [1]. This of
course became mandated by the Joint Commission for the
Accreditation of Healthcare Organizations (JCAHO) in
2000–2002, and the declaration by the US Congress calling
2001–2010 the “Decade of Pain Control and Research” [1].
Brennan, Carr, and Cousins go on to state that “if there is a
clear ethical duty to relieve suffering or to act virtuously by
doing so, then one may argue that from that duty springs a
right. The moral right to pain management emerges from, and
is directly founded upon, the duty of the doctor to act ethically.
Classically, the holder of a right has the capacity to enforce a
duty in a person or institution. That ‘other’ has a duty to fulfill
that right. Indeed, a basic tenet of the philosophy of rights is
that a right can only exist if there is a preexisting obligation. If
one accepts that a health professional has an obligation, where
appropriate, to manage pain, then the patient has a concomitant right, where appropriate, to receive such care” [
It is clear that this right to receive adequate pain manage-
ment is not more evident than in the postoperative surgical
patient (of any age). Yet fear of uncontrolled postsurgical
pain continues to be among the primary concerns of many
patients about to undergo surgery [2]. This fear is not
J.M. Berger (*)
Department of Anesthesiology, Keck School of Medicine,
University of Southern California, LAC + USA Medical Center,
Los Angeles, CA, USA
e-mail: JMBerger@usc.edu
1].
unfounded since, despite increasing research and clinical
attention, many adult surgical patients continue to experience moderate to severe pain [
been the result of the Joint Commission for the Accreditation
of Healthcare Organizations (JAHCO) initiative for better
pain management assessment and treatment as reported by
Frasco et al., who demonstrated that there has been an
increased use of morphine and prophylactic antiemetics in
postanesthesia recovery rooms without a concomitant
increase in length of stay in the recovery rooms [5].
The ill effects of inadequately treated pain in the acute
postoperative period are summarized by Sinatra [6]. Acute
pain leads to increased sympathetic activity which in turn
leads to tachycardia and hypertension [6]. In elderly patients
with coronary artery disease, the risk of myocardial infarction is therefore increased. Regional blood flow can be
impaired which may increase the risk of postoperative infection. Fear and anxiety resulting from inadequate pain control
can impair sleep and rehabilitation. Splinting and shallow
breathing can lead to hypoxemia, atelectasis, and pneumonia
[6] (Fig. 26.1).
Less well recognized is the fact that inadequate acute
postsurgical pain management can lead to chronic pain syndromes [7, 8]. Without belaboring the point further, it is clear
that these pathological effects of acute pain can lead to life
threatening consequences and can also lead to chronic neuropathic pain states that can affect the future quality of the
patient’s life through a constellation of maladaptive physical,
psychological, family, and social consequences. These
chronic neuropathic pain states can be regarded as true disease entities leading to dependence on medication, reduced
mobility, loss of strength, disturbances of sleep, and social
consequences that can result in dissolution of family relations [
9].
Ginsberg writing in Anesthesiology News, February 2002
commenting on a Canadian study of postoperative pain management states “Pain interferes with out-patients’ activities,
work, sleep, appetite, and concentration…Pain on the first
day after surgery can be expected. But in the Canadian study,
7 days after surgery, 50% of patients had pain that interfered
with activity or work, and 25% could not sleep because of
3, 4]. Some improvement has
R.A. Rosenthal et al. (eds.), Principles and Practice of Geriatric Surgery,
DOI 10.1007/978-1-4419-6999-6_26, © Springer Science+Business Media, LLC 2011
321
322 J.M. Berger
Tachycardia
Myocardial
ischemia
Sympathetic
activity
Regional blood
flows
Pulmonary
compromise
Hypoxia
Atelectasis
Demoralized
patient
Anxiety
Sleeplessness
PAIN
Hypercarbia
↑O
2
Consumption
Infection
https://t.me/med1917
Fi g u r e 26.1 Harmful effects of unrelieved acute pain (reprinted from
6], with permission from Elsevier).
Sinatra [
pain” [10]. Ginsberg goes on to state that “Physicians as
caregivers must take blame for inadequate pain treatment…
in the Canadian study on day 1, 60% were given a mild opioid…by day 7, they only received tender loving care and
chicken soup” [10].
These pathological consequences of uncontrolled pain
may have greater consequences in the elderly population
[11]. As the population ages, and surgical and anesthetic protocols become safer, the number of older patients undergoing
surgery will grow [12]. By the year 2050, there will be a
fourfold increase in the elderly population compared with
only a 50% global population increase, and at that time 25%
of the elderly will be over the age of 80 [13]. Elderly patients
have surgery four times more frequently than the younger
population [14].
However, there is little merit in considering the treatment
of acute pain in the elderly population unless it differs from
that provided to younger patients [13]. This begs the questions of whether elderly patients perceive pain differently
from younger patients; are there changes in nociception that
occur with aging, and do elderly patients process and respond
to nociception differently?
Issues in treating pain in the elderly can therefore be broken down to:
Sensitivity to painful stimuli – nociception•
Sensitivity of the central nervous system (CNS) (cogni-•
tive impairment)
Pharmacodynamics/pharmacokinetics, organ function, •
and aging
−
Metabolism of drugs (liver function)
Excretion of drugs (renal function) −
Social concerns – addiction, pseudoaddiction, depen-•
dence, and tolerance
Principles of titration of medications•
Role of interventional techniques and regional •
anesthetics
These issues will be addressed below.
Nociception Is Not Pain
Activity induced in the nociceptor and nociceptive pathways
by a noxious stimulus is not “pain,” which is always a psychological state. Although we appreciate that pain most often has
a proximate physical cause, especially acute pain, activity in
nociceptor systems is not equivalent to the “experience of
pain” [15]. The recognition that pain serves an important biologic function related to survival raises the important question:
to what extent do age-related changes in nociception impact
on the capacity of the pain experience to fulfill an “enteroceptive” function such as thirst, hunger, and thermoception that
constitute sensory indexes of the health of the body? [16]
Assessment and intervention for pain in the elderly should
therefore begin with the assumption that all neurophysiologic
processes subserving nociception are intact [17]. In fact
Gagliese and Melzack demonstrated that age did not affect
the rating of pain by postsurgical patients [18]. That is to say,
tissue injury produces the same intensity of stimulus in an
elderly person as in a young person.
There are data to suggest, however, that some impairment
of Ad fibers occurs with aging, and therefore impedes the
early warning of tissue injury [16]. There are also data that
suggest that widespread and substantial changes in structure,
neurochemistry, and function occur in the dorsal horn of the
spinal cord and CNS with aging [16].
Multiple studies report reductions in the descending inhibitory modulating systems for nociception in the elderly [16,
19]. Gibson and Ferrell conclude that the reduced efficacy of
endogenous analgesic systems might be expected to result in
a more severe pain experience following prolonged noxious
stimulation [16]. It is also possible that the documented
decline in afferent transmission pathways could be offset by a
commensurate reduction in the endogenous inhibitory mechanisms of older persons, with a net result of little or no change
in the perceptual pain experience [16]. They further conclude
that any deficit in endogenous analgesic response (which is
stimulus intensity dependent) will become critical, thereby
making it more difficult for persons of advanced age to cope
with severe or persistent clinical pain conditions [
Gibson reviewed the literature on pain threshold and tolerance in elderly patients [20]. Evidence suggests that as age
advances, pain threshold increases, but pain tolerance
decreases. The net effect may be that elderly patients experience acute surgical pain in the same way as younger patients.
It is clear that if a surgeon was to make a skin incision with a
scalpel in an elderly unanesthetized patient, then the patient
would most certainly scream with pain. Yet silent myocardial infarctions are more common in the elderly, and the
bowel must be more distended before the elderly sense pain,
often delaying the diagnosis of such conditions as a bowel
obstruction [20, 21].
16].
32326 Acute Postoperative Pain Management in Elderly Patients
https://t.me/med1917
With respect to the heart, the complete absence of “the
perception of pain” that can occur in the presence of myocardial ischemia, arteriolar occlusion, myocarditis, early acute
endocarditis, valvular ulceration, etc. makes it difficult and
yet extremely important to assess for pain in elderly patients
recovering from surgery [22].
But while there is controversy over whether the number
and integrity of nociceptors decreases with age, the clinical
position that age dulls the “sense of pain” is untenable [16].
It is the processing of the nociceptive information that may
be altered in the elderly, and the elderly may be more sensitive to the side effects of medications that are used to treat
pain. These observations thereby give the impression that the
elderly are less sensitive to pain. But no physiologic changes
in pain perception in the elderly have been demonstrated
according to a five-state study by Cleeland [21]. This is supported by the observation that age does not affect the success
of traditional interventions for the treatment of pain [17].
Again one would not assume that a surgical incision in an
elderly patient will “hurt” less and therefore does not need to
be treated. Likewise, anyone who has observed an elderly
patient with acute herpes zoster certainly can attest to the
excruciating pain that these unfortunate patients report. If
given adequate preoperative teaching, assessed preoperatively for any impediments to the use of patient-controlled
analgesia (PCA), e.g., dementia, elderly patients were successfully started on PCA in the postanesthesia care unit after
general anesthesia once they were awake and responsive
enough to receive a loading dose of opioids titrated to
comfort [17].
Postoperative Central Nervous System
Dysfunction
Postoperative CNS dysfunction is a common complication in
elderly surgical patients. Rohan and his associates reported
that the incidence of postoperative cognitive dysfunction
(POCD) in elderly patients on the first postoperative day
after minor surgery performed under general anesthesia
(either propofol or sevoflurane) was 47% compared with 7%
for matched nonsurgical hospitalized patients [23]. The acute
confusional state, postoperative delirium (POD), is also common and can occur in as many as 60% of patients depending
on preoperative risk factors and the type of surgery [16].
Preoperative confusion has been found to be a predictor of
POD [23]. Pain can lead to delirium which can complicate
pain assessment [24]. At the same time, the effect of pain in
patients who already have preexisting cognitive deficits or
dementia with loss of communication skills, or even loss of
basic reflexes (e.g., gag), may disturb the assessment of critical functions for the expression of pain [13].
Little is known of the neurophysiological relationships
between pain- and age-related degenerative brain diseases.
It has been reported that beginning at the age of 40 and continuing into late old age, there is reduced expression in the
human brain of genes involved in learning and memory and
neuronal survival [25]. But the ability for plasticity and new
dendritic synapses (i.e., memory) is preserved even into old
age [26].
It would appear that elderly patients are more susceptible
to confusion and cognitive impairment, but retain some
capacity to recover. It is not uncommon for elderly patients to
go through a period of delirium postoperatively, and although
recovery from the acute confusional state may be complete,
POCD may persist for far longer. This is manifested by the
complaint from the family that the elderly patient just never
seemed “quite the same” again after the operation.
Pharmacodynamics/Pharmacokinetics,
Organ Function, and Aging
Fine recently reviewed the issues of pharmacological management of persistent pain in older patients [27]. In general,
the pharmacodynamic actions of drugs (what the drug does
to the patient) are unaffected in the normal aging process.
The molecular action of morphine is the same in all animals,
although dose requirements to produce the same effect may
change with age, and the therapeutic window between
intended effect and side or adverse effects may be narrowed
in the elderly [28, 29]. However, since centrally acting drugs
may interact with a preexisting disease state, care must be
taken when treating pain in patients with CNS disease such
as Parkinsonism, Alzheimer dementia, or stroke.
The pharmacokinetic actions of drugs (what the patient
does to the drug), on the other hand, are frequently affected
by aging processes and disease states. Pharmacokinetic
changes due to physical aging may complicate medication
management [30]. Woodhouse and Mathur studied the 24-h
cumulative PCA opioid administration as a function of age,
and found that morphine and fentanyl both showed the
expected reduction in dose by 50% in the elderly, but meperidine was more variable due to a more complex pharmacology [31]. This 50% reduction in PCA opioid analgesia
requirement in elderly surgical patients compared with
younger patients was confirmed by other investigators [17].
The patients in this study showed comparable levels of pain
relief and satisfaction with this technology. Opioids have
been shown to produce a greater incidence of respiratory
depression in the elderly, but the elderly seem to be less sensitive with respect to nausea and vomiting [32].
The most important generalization from physiologic
studies of aging is that although the basal function of the
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