Skip to main content
SpringerLink
Log in

Practical Management of Anaesthesia in the Elderly

  • Therapy in Practice
  • Published:
Drugs & Aging Aims and scope Submit manuscript

Abstract

The elderly population is rapidly growing and particularly diverse. Ageing leads to reduced organ function and a decline in physiologic reserve. Elderly patients are characterised by great inter-individual variability in physiological function with a high prevalence of chronic disease. In general, older patients have a higher risk of postoperative adverse outcomes, and frailty is a very important risk factor. This review article aims to provide a practical guide to anaesthetic management of the elderly surgical patient. To optimise care, clinicians should be familiar with the typical physiologic changes related to ageing and the implications for anaesthetic management. All anaesthetic techniques, methods and agents can be applied, if tailored to the patient’s physiologic and pathologic changes. The elderly are more sensitive to anaesthetics, meaning that desired sedative and analgesic effects are reached at lower doses compared with younger patients, and the haemodynamic depressing side effects of anaesthetics are often more pronounced. To reduce the risk of circulatory collapse, the clinician should carefully titrate anaesthetics and await the response with patience. The dose of neuromuscular blocking agents should rarely be reduced for intubation, but the duration of action of neuromuscular blocking agents is often prolonged and difficult to predict. Perioperative neuromuscular monitoring is therefore strongly recommended. In the postoperative period, prevention of avoidable morbidity and functional decline is crucial; comprehensive multidisciplinary care and multimodal interventions may facilitate earlier recovery and decrease the risk of complications.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Clegg A, Young J, Iliffe S, et al. Frailty in elderly people. Lancet. 2013;381:752–62. doi:10.1016/S0140-6736(12)62167-9.

    Article  PubMed  Google Scholar 

  2. Aunan JR, Watson MM, Hagland HR, Søreide K. Molecular and biological hallmarks of ageing. Br J Surg. 2016;103:e29–46. doi:10.1002/bjs.10053.

    Article  CAS  PubMed  Google Scholar 

  3. Moller J, Cluitmans P, Rasmussen L, et al. Long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study. Lancet. 1998;351:857–61. doi:10.1016/S0140-6736(97)07382-0.

    Article  CAS  PubMed  Google Scholar 

  4. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56:M146–56.

    Article  CAS  PubMed  Google Scholar 

  5. Oakland K, Nadler R, Cresswell L, et al. Systematic review and meta-analysis of the association between frailty and outcome in surgical patients. Ann R Coll Surg Engl. 2016;8:80–5. doi:10.1308/rcsann.2016.0048.

    Article  Google Scholar 

  6. Brody KK, Johnson RE, Douglas Ried L. Evaluation of a self-report screening instrument to predict frailty outcomes in aging populations. Gerontologist. 1997;37:182–91.

    Article  CAS  PubMed  Google Scholar 

  7. Oresanya LB, Lyons WL, Finlayson E. Preoperative assessment of the older patient: a narrative review. JAMA. 2014;311:2110–20. doi:10.1001/jama.2014.4573.

    Article  CAS  PubMed  Google Scholar 

  8. Makary MA, Segev DL, Pronovost PJ, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210:901–8. doi:10.1016/j.jamcollsurg.2010.01.028.

    Article  PubMed  Google Scholar 

  9. Turrentine FE, Wang H, Simpson VB, Jones RS. Surgical risk factors, morbidity, and mortality in elderly patients. J Am Coll Surg. 2006;203:865–77. doi:10.1016/j.jamcollsurg.2006.08.026.

    Article  PubMed  Google Scholar 

  10. Wolters U, Wolf T, Stützer H, Schröder T. ASA classification and perioperative variables as predictors of postoperative outcome. Br J Anaesth. 1996;77:217–22.

    Article  CAS  PubMed  Google Scholar 

  11. NSQIP/ASC. Risk calculator. http://riskcalculator.facs.org/RiskCalculator. Accessed 4 Oct 2016.

  12. The Criteria Committee of the New York Heart Association. Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. 9th ed. Boston: Little, Brown & Co.; 1994. pp. 253–6.

  13. Campeau L. Letter: grading of angina pectoris. Circulation. 1976;54:522–3.

    CAS  PubMed  Google Scholar 

  14. Monk TG, Weldon BC, Garvan CW, et al. Predictors of cognitive dysfunction after major noncardiac surgery. Anesthesiology. 2008;108:18–30. doi:10.1097/01.anes.0000296071.19434.1e.

    Article  PubMed  Google Scholar 

  15. Borson S, Scanlan J, Brush M, et al. The mini-cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000;15:1021–7.

    Article  CAS  PubMed  Google Scholar 

  16. Barry PJ, Gallagher P, Ryan C, O’Mahony D. START (screening tool to alert doctors to the right treatment): an evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing. 2007;36:632–8. doi:10.1093/ageing/afm118.

    Article  CAS  PubMed  Google Scholar 

  17. Liu LL, Dzankic S, Leung JM. Preoperative electrocardiogram abnormalities do not predict postoperative cardiac complications in geriatric surgical patients. J Am Geriatr Soc. 2002;50:1186–91.

    Article  PubMed  Google Scholar 

  18. Dzankic S, Pastor D, Gonzalez C, Leung JM. The prevalence and predictive value of abnormal preoperative laboratory tests in elderly surgical patients. Anesth Analg. 2001;93:301–8, 2nd contents page.

  19. Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly: an update. Arch Intern Med. 1997;157:1531–6. doi:10.1001/archinte.157.14.1531.

    Article  CAS  PubMed  Google Scholar 

  20. O’Mahony D, Gallagher P, Ryan C, et al. STOPP & START criteria: a new approach to detecting potentially inappropriate prescribing in old age. Eur Geriatr Med. 2010;1:45–51. doi:10.1016/j.eurger.2010.01.007.

    Article  Google Scholar 

  21. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis. 9th ed. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141:e326S–50S. doi:10.1378/chest.11-2298.

  22. Spyropoulos AC. Bridging therapy and oral anticoagulation: current and future prospects. Curr Opin Hematol. 2010;17:444–9. doi:10.1097/MOH.0b013e32833c077b.

    Article  CAS  PubMed  Google Scholar 

  23. Tumer N, Scarpace PJ, Lowenthal DT. Geriatric pharmacology: basic and clinical considerations. Annu Rev Pharmacol Toxicol. 1992;32:271–302. doi:10.1146/annurev.pa.32.040192.001415.

    Article  CAS  PubMed  Google Scholar 

  24. Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ. Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev; 2011;(2):CD007635. doi:10.1002/14651858.CD007635.pub2.

  25. Wind J, Polle SW, Fung Kon Jin PHP, et al. Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg. 2006;93:800–9. doi:10.1002/bjs.5384.

    Article  CAS  PubMed  Google Scholar 

  26. Bagnall NM, Malietzis G, Kennedy RH, et al. A systematic review of enhanced recovery care after colorectal surgery in elderly patients. Colorectal Dis. 2014;16:947–56. doi:10.1111/codi.12718.

    Article  CAS  PubMed  Google Scholar 

  27. Khan MA, Pandey S. Clinical outcomes of the very elderly undergoing enhanced recovery programmes in elective colorectal surgery. Ann R Coll Surg Engl. 2016;98:29–33. doi:10.1308/rcsann.2015.0036.

    Article  CAS  PubMed  Google Scholar 

  28. Rasmussen LS, Johnson T, Kuipers HM, et al. Does anaesthesia cause postoperative cognitive dysfunction? A randomised study of regional versus general anaesthesia in 438 elderly patients. Acta Anaesthesiol Scand. 2003;47:260–6.

    Article  CAS  PubMed  Google Scholar 

  29. Wu CL, Hsu W, Richman JM. Raja SN Postoperative cognitive function as an outcome of regional anesthesia and analgesia. Reg Anesth Pain Med. 2004;29:257–68.

    Article  CAS  PubMed  Google Scholar 

  30. Guay J, Choi PT, Suresh S, et al. Neuraxial anesthesia for the prevention of postoperative mortality and major morbidity: an overview of cochrane systematic reviews. Anesth Analg. 2014;119:716–25. doi:10.1213/ANE.0000000000000339.

    Article  CAS  PubMed  Google Scholar 

  31. Chu C-C, Weng S-F, Chen K-T, et al. Propensity score-matched comparison of postoperative adverse outcomes between geriatric patients given a general or a neuraxial anesthetic for hip surgery: a population-based study. Anesthesiology. 2015;123:136–47. doi:10.1097/ALN.0000000000000695.

    Article  PubMed  Google Scholar 

  32. Guay J, Choi P, Suresh S, et al. Neuraxial blockade for the prevention of postoperative mortality and major morbidity: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev. 2014;(1):CD010108. doi:10.1002/14651858.CD010108.pub2.

  33. Guay J, Parker MJ, Gajendragadkar PR, Kopp S. Anaesthesia for hip fracture surgery in adults. Cochrane Database Syst Rev. 2016;(2):CD000521. doi:10.1002/14651858.CD000521.pub3.

  34. Kazmierski J, Kowman M, Banach M, et al. Incidence and predictors of delirium after cardiac surgery: results from The IPDACS Study. J Psychosom Res. 2010;69:179–85. doi:10.1016/j.jpsychores.2010.02.009.

    Article  PubMed  Google Scholar 

  35. van Harten AE, Scheeren TWL, Absalom AR. A review of postoperative cognitive dysfunction and neuroinflammation associated with cardiac surgery and anaesthesia. Anaesthesia. 2012;67:280–93. doi:10.1111/j.1365-2044.2011.07008.x.

    Article  PubMed  Google Scholar 

  36. Hogue CW, Palin CA, Arrowsmith JE. Cardiopulmonary bypass management and neurologic outcomes: an evidence-based appraisal of current practices. Anesth Analg. 2006;103:21–37. doi:10.1213/01.ANE.0000220035.82989.79.

    Article  PubMed  Google Scholar 

  37. Cusack BJ. Pharmacokinetics in older persons. Am J Geriatr Pharmacother. 2004;2:274–302. doi:10.1016/j.amjopharm.2004.12.005.

    Article  CAS  PubMed  Google Scholar 

  38. Myles PS, Leslie K, Chan MTV, et al. The safety of addition of nitrous oxide to general anaesthesia in at-risk patients having major non-cardiac surgery (ENIGMA-II): a randomised, single-blind trial. Lancet. 2014;384:1446–54. doi:10.1016/S0140-6736(14)60893-X.

    Article  CAS  PubMed  Google Scholar 

  39. Nickalls RWD, Mapleson WW. Age-related iso-MAC charts for isoflurane, sevoflurane and desflurane in man. Br J Anaesth. 2003;91:170–4. doi:10.1093/bja/aeg132.

    Article  CAS  PubMed  Google Scholar 

  40. Schnider TW, Minto CF, Shafer SL, et al. The influence of age on propofol pharmacodynamics. Anesthesiology. 1999;90:1502–16.

    Article  CAS  PubMed  Google Scholar 

  41. Stanski DR, Maitre PO. Population pharmacokinetics and pharmacodynamics of thiopental: the effect of age revisited. Anesthesiology. 1990;72:412–22.

    Article  CAS  PubMed  Google Scholar 

  42. Arden JR, Holley FO, Stanski DR. Increased sensitivity to etomidate in the elderly: initial distribution versus altered brain response. Anesthesiology. 1986;65:19–27.

    Article  CAS  PubMed  Google Scholar 

  43. Reves JG, Fragen RJ, Vinik HR, Greenblatt DJ. Midazolam: pharmacology and uses. Anesthesiology. 1985;62:310–24.

    Article  CAS  PubMed  Google Scholar 

  44. Egan TD, Kern SE, Muir KT, White J. Remifentanil by bolus injection: a safety, pharmacokinetic, pharmacodynamic, and age effect investigation in human volunteers. Br J Anaesth. 2004;92:335–43. doi:10.1093/bja/aeh075.

    Article  CAS  PubMed  Google Scholar 

  45. Minto CF, Schnider TW, Shafer SL. Pharmacokinetics and pharmacodynamics of remifentanil. II. Model application. Anesthesiology. 1997;86:24–33.

    Article  CAS  PubMed  Google Scholar 

  46. Murphy GS, Szokol JW, Avram MJ, et al. Residual neuromuscular block in the elderly: incidence and clinical implications. Anesthesiology. 2015;123:1322–36. doi:10.1097/ALN.0000000000000865.

    Article  PubMed  Google Scholar 

  47. Arain SR, Kern S, Ficke DJ, Ebert TJ. Variability of duration of action of neuromuscular-blocking drugs in elderly patients. Acta Anaesthesiol Scand. 2005;49:312–5. doi:10.1111/j.1399-6576.2005.00634.x.

    Article  CAS  PubMed  Google Scholar 

  48. Tsui BCH, Wagner A, Finucane B. Regional anaesthesia in the elderly: a clinical guide. Drugs Aging. 2004;21:895–910.

    Article  PubMed  Google Scholar 

  49. Simon MJG, Veering BT, Stienstra R, et al. Effect of age on the clinical profile and systemic absorption and disposition of levobupivacaine after epidural administration. Br J Anaesth. 2004;93:512–20. doi:10.1093/bja/aeh241.

    Article  CAS  PubMed  Google Scholar 

  50. Racle JP, Benkhadra A, Poy JY, Gleizal B. Spinal analgesia with hyperbaric bupivacaine: influence of age. Br J Anaesth. 1988;60:508–14.

    Article  CAS  PubMed  Google Scholar 

  51. Qureshi SH, Rizvi SI, Patel NN, Murphy GJ. Meta-analysis of colloids versus crystalloids in critically ill, trauma and surgical patients. Br J Surg. 2016;103:14–26. doi:10.1002/bjs.9943.

    Article  CAS  PubMed  Google Scholar 

  52. Guralnik JM, Eisenstaedt RS, Ferrucci L, et al. Prevalence of anemia in persons 65 years and older in the United States: evidence for a high rate of unexplained anemia. Blood. 2004;104:2263–8.

    Article  CAS  PubMed  Google Scholar 

  53. Brunskill SJ, Millette SL, Shokoohi A, et al. Red blood cell transfusion for people undergoing hip fracture surgery. Cochrane Database Syst Rev. 2015;4:CD009699. doi:10.1002/14651858.CD009699.pub2.

  54. Adams SD, Cotton BA, McGuire MF, et al. Unique pattern of complications in elderly trauma patients at a level I trauma center. J Trauma Acute Care Surg. 2012;72:112–8. doi:10.1097/TA.0b013e318241f073.

    Article  PubMed  Google Scholar 

  55. Kruse-Jarres R. Acquired bleeding disorders in the elderly. Hematology Am Soc Hematol Educ Program. 2015;2015:231–6. doi:10.1182/asheducation-2015.1.231.

    PubMed  Google Scholar 

  56. Frank SM, Fleisher LA, Breslow MJ, et al. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events: a randomized clinical trial. JAMA. 1997;277:1127–34.

    Article  CAS  PubMed  Google Scholar 

  57. Renner J, Grünewald M, Bein B, et al. Monitoring high-risk patients: minimally invasive and non-invasive possibilities. Best Pract Res Clin Anaesthesiol. 2016;30:201–16. doi:10.1016/j.bpa.2016.04.006.

    Article  PubMed  Google Scholar 

  58. Siddiqi N, Harrison JK, Clegg A, et al. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev. 2016;3:CD005563. doi:10.1002/14651858.CD005563.pub3.

  59. Sieber FE, Zakriya KJ, Gottschalk A, et al. Sedation depth during spinal anesthesia and the development of postoperative delirium in elderly patients undergoing hip fracture repair. Mayo Clin Proc. 2010;85:18–26. doi:10.4065/mcp.2009.0469.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Ng A, Smith G. Gastroesophageal reflux and aspiration of gastric contents in anesthetic practice. Anesth Analg. 2001;93:494–513.

    CAS  PubMed  Google Scholar 

  61. Gibson SJ, Helme RD. Age-related differences in pain perception and report. Clin Geriatr Med. 2001;17:433–56, v–vi.

  62. Kheterpal S, Tremper KK, Heung M, et al. Development and validation of an acute kidney injury risk index for patients undergoing general surgery: results from a national data set. Anesthesiology. 2009;110:505–15. doi:10.1097/ALN.0b013e3181979440.

    Article  PubMed  Google Scholar 

  63. Tse L, Schwarz SK, Bowering JB, et al. Pharmacological risk factors for delirium after cardiac surgery: a review. Curr Neuropharmacol. 2012;10:181–96. doi:10.2174/157015912803217332.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  64. Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment method: a new method for detection of delirium. Ann Intern Med. 1990;113:941–8.

    Article  CAS  PubMed  Google Scholar 

  65. Whitlock EL, Torres BA, Lin N, et al. Postoperative delirium in a substudy of cardiothoracic surgical patients in the BAG-RECALL clinical trial. Anesth Analg. 2014;118:809–17. doi:10.1213/ANE.0000000000000028.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  66. Inouye SK, Westendorp RG, Saczynski JS, et al. Delirium in elderly people. Lancet. 2014;383:911–22. doi:10.1016/S0140-6736(13)60688-1.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark

    Camilla Strøm, Lars Simon Rasmussen & Jacob Steinmetz

Authors
  1. Camilla Strøm
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lars Simon Rasmussen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jacob Steinmetz
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Camilla Strøm.

Ethics declarations

Funding

CS is supported by the Region Zealand Research Foundation and LSR is supported by the Tryg Foundation.

Conflict of interest

CS, LR and JS have no conflicts of interest directly relevant to the content of this article.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Strøm, C., Rasmussen, L.S. & Steinmetz, J. Practical Management of Anaesthesia in the Elderly. Drugs Aging 33, 765–777 (2016). https://doi.org/10.1007/s40266-016-0413-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40266-016-0413-y

Keywords

Search

Navigation