Geriatric Neuroanesthesia

  • Kiran Jangra
  • Shiv Lal Soni


As we are growing grayer, our expectations are also growing, and neurosurgical interventions are also being increasingly done in the elderly patients. There are various studies that show surgeries in elderly patients are successful most of the times and can avoid long-term disability and dependence, and age alone should not be the criteria to decide in favor or against the surgery. It is the presence and severity of coexisting pathology that govern the outcome in these patients rather than age alone. In traumatic and emergency surgeries, age directly affects the outcome, and geriatric patients with severe trauma usually carry a poor prognosis. With adequate preoperative optimization, skillful perioperative management, and clinical common sense, a good outcome can be achieved in elderly neurosurgical patient. In recent era, the development of advanced technology, new equipment, and neuroanesthesia/neurointensive care has expanded and revolutionized the daily neurosurgical practice. These techniques have enlarged the spectrum of conditions that are amenable to neurosurgical management. The proportion of geriatric population is following an increasing trend. The optimal management of geriatric patients is a challenge due to their depleted systemic reserves, polypharmacy, and geriatric syndromes. As compared to the younger patients, geriatric patients are at higher risk of adverse perioperative outcomes. A strong evidence is required to conclude whether neurosurgical intervention actually benefits these elderly patients or just increase the risk of perioperative morbidity and mortality. A multidisciplinary team approach involving emergency medicine experts, geriatricians, surgeons, anesthetists, and intensivists should work together to improve outcome in these patients.


Geriatric patients Neuroanesthesia Neurosurgery 


  1. 1.
    Ausman JI. Achievements of the last century in neurosurgery and a view to the 21st century. Surg Neurol. 2000;53(4):301–2.PubMedCrossRefGoogle Scholar
  2. 2.
    Hutchins LF, et al. Underrepresentation of patients 65 years of age or older in cancer-treatment trials. N Engl J Med. 1999;341(27):2061–7.PubMedCrossRefGoogle Scholar
  3. 3.
    RS M-W. Neurosurgery in the elderly. Br J Neurosurg. 1994;8(6):651–3.CrossRefGoogle Scholar
  4. 4.
    Maurice-Williams RS, Kitchen N. The scope of neurosurgery for elderly people. Age Ageing. 1993;22(5):337–42.PubMedCrossRefGoogle Scholar
  5. 5.
    O’Brien DP, Nagaria J, Rawluk D. Neurosurgery for the elderly: facts and figures. Gerontology. 1996;42(1):1–6.PubMedCrossRefGoogle Scholar
  6. 6.
    Whitehouse KJ, Jeyaretna DS, Wright A, Whitfield PC. Neurosurgical care in the elderly: increasing demands necessitate future healthcare planning. World Neurosurg. 2016;87:446–54.PubMedCrossRefGoogle Scholar
  7. 7.
    Meiner SE. Theories of aging. In: Meiner SE, editor. Gerontologic nursing. 4th ed. St Louis: Elsevier; 2011. p. 15–27.Google Scholar
  8. 8.
    Jackson MJ. Skeletal muscle aging: role of reactive oxygen species. Crit Care Med. 2009;37(10 Suppl):S368–71.PubMedCrossRefGoogle Scholar
  9. 9.
    Woo J, Leung J, Kwok T. BMI, body composition, and physical functioning in older adults. Obesity (Silver Spring). 2007;15(7):1886–94.CrossRefGoogle Scholar
  10. 10.
    Eliopoulos C. Common aging signs. In: Eliopoulos C, editor. Gerontological nursing. 7th ed. New York: Lippincott Williams & Wilkins; 2010. p. 49–65.Google Scholar
  11. 11.
    Mick DJ, Ackerman MH. Critical care nursing for older adults: pathophysiological and functional considerations. Nurs Clin North Am. 2004;39(3):473–93.PubMedCrossRefGoogle Scholar
  12. 12.
    Rabbitt P, Scott M, Lunn M, et al. White matter lesions account for all age-related declines in speed but not in intelligence. Neuropsychology. 2007;21(3):363–70.PubMedCrossRefGoogle Scholar
  13. 13.
    Mamaril ME. Nursing considerations in the geriatric surgical patient: the perioperative continuum of care. Nurs Clin North Am. 2006;41(2):313–28.PubMedCrossRefGoogle Scholar
  14. 14.
    Plassman BL, Langa KM, Fisher GG, et al. Prevalence of dementia in the United States: the aging, demographics, and memory study. Neuroepidemiology. 2007;29(1–2):125–32.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Friedman S. Sensory function. In: Meiner SE, editor. Gerontologic nursing. 4th ed. St Louis: Elsevier; 2011. p. 628–45.Google Scholar
  16. 16.
    Go AS, Mozaffarian D, Roger VL, American Heart Association Statistics Committee and Stroke Statistics Subcommittee, et al. Heart disease and stroke statistics-2014 update: a report from the American Heart Association. Circulation. 2014;129(3):e28–e292.PubMedGoogle Scholar
  17. 17.
    Menaker J, Scalea TM. Geriatric care in the surgical intensive care unit. Crit Care Med. 2010;38(9 Suppl):S452–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Morley JE, Reese SS. Clinical implications of the aging heart. Am J Med. 1989;86(1):77–86.PubMedCrossRefGoogle Scholar
  19. 19.
    Marik PE. Management of the critically ill geriatric patient. Crit Care Med. 2006;34(9 Suppl):S176–82.PubMedCrossRefGoogle Scholar
  20. 20.
    Rosenthal RA, Kavic SM. Assessment and management of the geriatric patient. Crit Care Med. 2004;32(4 Suppl):S92–S105.PubMedCrossRefGoogle Scholar
  21. 21.
    Pisani MA. Considerations in caring for the critically ill older adult. J Intensive Care Med. 2009;24(2):83–95.PubMedCrossRefGoogle Scholar
  22. 22.
    Corcoran TB, Hillyard S. Cardiopulmonary aspects of anaesthesia for the elderly. Best Pract Res Clin Anaesthesiol. 2011;25:329–54.PubMedCrossRefGoogle Scholar
  23. 23.
    Nagappan R, Parkin G. Geriatric critical care. Crit Care Clin. 2003;19(2):253–70.PubMedCrossRefGoogle Scholar
  24. 24.
    Saber A. Perioperative care of elderly surgical patients. Am Med J. 2013;4(1):63–77.Google Scholar
  25. 25.
    Walker M, Spivak M, Sebastian M. The impact of aging physiology in critical care. Crit Care Nurs Clin North Am. 2014;26(1):7–14.PubMedCrossRefGoogle Scholar
  26. 26.
    Presta P, Lucisano G, Fuiano L, Fuiano G. The kidney and the elderly: why does the risk increase? Int Urol Nephrol. 2012;44:625–32.PubMedCrossRefGoogle Scholar
  27. 27.
    Stamm LA, Wiersema-Bryant LA, Ward C. Gastrointestinal function. In: Meiner SE, editor. Gerontologic nursing. 4th ed. St Louis: Elsevier; 2011. p. 482–516.Google Scholar
  28. 28.
    Grassi M, Petraccia L, Mennuni G, et al. Changes, functional disorders, and diseases in the gastrointestinal tract of elderly. Nutr Hosp. 2011;26(4):659–68.PubMedGoogle Scholar
  29. 29.
    Schmucker DL. Age-related changes in liver structure and function: implications for disease? Exp Gerontol. 2005;40(8–9):650–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Gong Z, Muzumdar RH. Pancreatic function, type 2 diabetes and metabolism in aging. Int J Endocrinol. 2012;2012:320–482.CrossRefGoogle Scholar
  31. 31.
    Upadhyaya RC. Musculoskeletal function. In: Meiner SE, editor. Gerontologic nursing. 4th ed. St Louis: Elsevier; 2011. p. 517–44.Google Scholar
  32. 32.
    Friedman S. Integumentary function. In: Meiner SE, editor. Gerontologic nursing. 4th ed. St Louis: Elsevier; 2011. p. 596–627.Google Scholar
  33. 33.
    Mercer S, Guha A, Ramesh V. The P-POSSUM scoring systems for predicting the mortality of neurosurgical patients undergoing craniotomy: further validation of usefulness and application across healthcare systems. Indian J Anaesth. 2013;57:587–91.PubMedPubMedCentralCrossRefGoogle Scholar
  34. 34.
    Royal College of Surgeons of England. Emergency surgery. Standards for unscheduled surgical care. 2011. standardsforunscheduledcare/@@download/pdffile/rcs_emergency_surgery_2011_web.pdf. Accessed 5 Oct 2013.
  35. 35.
    Peden CJ, Grocott MPW. National Research Strategies: what outcomes are important in peri-operative elderly care? Anaesthesia. 2014;69(Suppl 1):61–9.PubMedCrossRefGoogle Scholar
  36. 36.
    Stoneham M, Murray D, Foss N. Emergency surgery: the big three – abdominal aortic aneurysm, laparotomy and hip fracture. Anaesthesia. 2014;69(Suppl 1):70–80.PubMedCrossRefGoogle Scholar
  37. 37.
    Carlisle JB. Pre-operative co-morbidity and postoperative survival in the elderly: beyond one lunar orbit. Anaesthesia. 2014;69(Suppl 1):17–25.PubMedCrossRefGoogle Scholar
  38. 38.
    Partridge J, Harari D, Martin F, Dhesi J. The impact of preoperative comprehensive geriatric assessment on postoperative outcomes in older patients undergoing scheduled surgery: a systematic review. Anaesthesia. 2014;69(Suppl 1):8–16.PubMedCrossRefGoogle Scholar
  39. 39.
    Martin F. Comprehensive assessment of the frail older patient. Accessed 5 Oct 2013.
  40. 40.
    Association of Anaesthetists of Great Britain and Ireland. Preoperative assessment and patient preparation. The Role of the Anaesthetist. 2010. Accessed 5 Oct 2013.
  41. 41.
    National Institute for Health and Care Excellence. CG 3. Preoperative tests. The use of routine preoperative tests for elective surgery. 2003. Accessed 5 Oct 2013.
  42. 42.
    Kozek-Langenecker SA, Afshari A, Albaladejo P, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2013;30:270–382.PubMedCrossRefGoogle Scholar
  43. 43.
    Goodnough LT, Maniatis A, Earnshaw P, et al. Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. Br J Anaesth. 2011;106:13–22.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Smith I, Kranke P, Murat I, et al. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2011;28:556–69.PubMedCrossRefGoogle Scholar
  45. 45.
    White SM. Legal and ethical aspects of anaesthesia for the elderly. Anaesthesia. 2014;69(Suppl 1):45–53.PubMedCrossRefGoogle Scholar
  46. 46.
    National Confidential Enquiry into Patient Outcome and Death. Elective and emergency surgery in the elderly: an age old problem. 2010. Accessed 5 Oct 2013.
  47. 47.
    National Institute for Health and Care Excellence. CG 65. Inadvertent perioperative hypothermia. 2008. Accessed 5 Oct 2013.
  48. 48.
    Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008;134:172–8.PubMedCrossRefGoogle Scholar
  49. 49.
    Ghosh S, Arthur B, Klein AA. NICE guidance on Cardio QTM oesophageal Doppler monitoring. Anaesthesia. 2012;66:1081–3.CrossRefGoogle Scholar
  50. 50.
    Morris C. Oesophageal Doppler monitoring, doubt and equipoise: evidence based medicine means change. Anaesthesia. 2013;68:684–8.PubMedCrossRefGoogle Scholar
  51. 51.
    Lerou JG. Nomogram to estimate age-related MAC. Br J Anaesth. 2004;93:288–91.PubMedCrossRefGoogle Scholar
  52. 52.
    Sieber FE, Gottshalk A, Zakriya KJ, Mears SC, Lee H. General anesthesia occurs frequently in elderly patients during propofol-based sedation and spinal anesthesia. J Clin Anesth. 2010;22:179–83.PubMedCrossRefGoogle Scholar
  53. 53.
    Ekstein M, Gavish D, Ezri T, Weinbroum AA. Monitored anaesthesia care in the elderly: guidelines and recommendations. Drugs Aging. 2008;25:477–500.PubMedCrossRefGoogle Scholar
  54. 54.
    Sessler DI, Sigl JC, Kelley SD, et al. Hospital stay and mortality are increased in patients having a “triple low” of low blood pressure, low bispectral index, and low minimum alveolar concentration of volatile anesthesia. Anesthesiology. 2012;116:1195–203.PubMedCrossRefGoogle Scholar
  55. 55.
    Pietraszewski P, Gaszynski T. Residual neuromuscular block in elderly patients after surgical procedures under general anaesthesia with rocuronium. Anaesthesiol Intensive Ther. 2013;45:77–81.PubMedCrossRefGoogle Scholar
  56. 56.
    Steinmetz J, Rasmussen LS. The elderly and general anaesthesia. Minerva Anestesiol. 2010;76:745–52.PubMedGoogle Scholar
  57. 57.
    Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New Eng J Med. 2009;360:491–9.PubMedCrossRefGoogle Scholar
  58. 58.
    Carotid Surgery Trialists’ Collaborative Group. MRC European carotid surgery trial: interim results for symptomatic patients with severe (70-99%) or with mild (0--29%) carotid stenosis. Lancet. 1991;337:1235–43.CrossRefGoogle Scholar
  59. 59.
    Perler BA, Williams GM. Carotid endarterectomy in the very elderly: is it worthwhile? Surgery. 1994;116:479–83.PubMedGoogle Scholar
  60. 60.
    Garrioch MA, Fitch W. Anaesthesia for carotid artery surgery. Br J Anaesth. 1993;71:569–79.PubMedCrossRefGoogle Scholar
  61. 61.
    Harbangh KS, Harbangh RE. Arteriovenous malformations in elderly patients. Neurosurgery. 1994;35:579–84.CrossRefGoogle Scholar
  62. 62.
    Zachariah SB, Zachariah B, Wang T, Balducci L. Primary brain tumors in the older patient: an annotated review. J Am Geriatr Soc. 1992;40:1265–71.PubMedCrossRefGoogle Scholar
  63. 63.
    Vecht CJ. Effect of age on treatment decisions in low-grade glioma. J Neurol Neurosttrg Psychiatry. 1993;56:1259–64.CrossRefGoogle Scholar
  64. 64.
    Maurice-Williams RS, Kitchen ND. Intracranial tumours in the elderly: the effect of age on the outcome of first time surgery for meningiomas. Br J Neurosurg. 1992;6:131–7.PubMedCrossRefGoogle Scholar
  65. 65.
    Umansky F, Ashkenazi E, Gertel M, Shalit MN. Surgical outcome in an elderly population with intracranial meningioma. J Neurol Neurosurg Psychiatry. 1992;55:481–5.PubMedPubMedCentralCrossRefGoogle Scholar
  66. 66.
    Zigler JE, Capen DA, Rithman SLG. Spinal disease in the aged. Clin Orthop. 1995;316:70–9.CrossRefGoogle Scholar
  67. 67.
    Howard MA, Gross AS, Dacen RG, Winn HR. Acute subdural haematomas: an age dependent clinical entity. J Neurosurg. 1989;71:858–63.PubMedCrossRefGoogle Scholar
  68. 68.
    Vinuela F, Halbach VV, Dion JE. Interventional neuroradiology. New York: Raven Press; 1992.Google Scholar
  69. 69.
    Venkatraghavan L, Manninen P, Mak P, Lukitto K, Hodaie M, Lozano A. Anesthesia for functional neurosurgery: review of complications. J Neurosurg Anesthesiol. 2006;18:64–7.PubMedCrossRefGoogle Scholar
  70. 70.
    Dodds C, Kumar C, Veering B, editors. Oxford textbook of anaesthesia for the elderly patient. Oxford: Oxford University Press; 2014.Google Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  • Kiran Jangra
    • 1
  • Shiv Lal Soni
    • 1
  1. 1.Department of Anaesthesia and Intensive CarePostgraduate Institute of Medical Education and ResearchChandigarhIndia

Personalised recommendations