Updates in Anesthetic Management of Geriatric Patients undergoing Orthopedic Surgery

Abstract

In recent years a growing interest has revolved round the impact of surgery and anesthesia on the elderly. As life expectancy increases with more elderly patients undergoing surgery, it is imperative that knowledge on this important topic is disseminated for health care systems and providers to understand why elderly are different and how management needs to be modified to improve outcome. Especially postoperative cognitive decline is much more common in the elderly and this has been associated with higher morbidity and mortality among elderly, which challenges the benefits of surgery in this population. Ageing is a physiological process, where the structure and functional capacity of organs and tissue progressively degenerates overtime. The ageing process is extra-ordinarily complex, and is constantly influenced by numerous factors; such as life style choices, environment, genetics, and social network and chronic diseases. The geriatric population has a higher prevalence of numerous medical conditions and comorbidity; including atherosclerosis, heart failure, diabetes, chronic obstructive lung disease, kidney impairment, and dementia. Of ten patients receives ever al drugs for their chronic diseases, which may have negative connotations. Polypharmacy can be associated with increased risk of adverse drug reactions, problematic drug interactions, and medication errors. Humans age differently, for which reason the elderly patient population is health-wise extremely diverse. A large proportion of elderly is functionally independent; they are healthy or have well treated milder chronic diseases. However, a significant proportion of elderly are particularly frail; they have severe chronic diseases, high level of comorbidity, and may have low functional capacity. The human body has the capability to compensate for the age related changes to some extent, but elderly, healthy or sick, have a limited physiological reserve that can become evident upon application of stressors. The increased frailty renders the elderly patient at risk of transient dis- abilities. This can potentially push the elderly into a vicious cycle that ultimately may lead to permanent loss of daily functions, loss of self-care capacity, and dependence on supportive care or institutionalization. Clinicians should be particularly aware of tailoring care and support to the individual patient's needs, and for the elderly this may include careful considerations on how to prevent functional decline and disabilities. A preoperative consultation is essential to evaluate the perioperative risks and plan preventive perioperative actions. It is important to address all the aspects of the elderly patient, which include changes induced by the process of aging, the cumulative impact of co-existing diseases ,presence of polypharmacy, difficulties in communication and comprehension(reduced hearing or vision),compromised cognitive function, and a consideration whether the patient can provide informed consent. It should always be considered, where a certain procedure for the individual patient could be best carried out. Certain patients should only be treated in places where supportive care and increased monitoring are available, for example elderly patients with bleeding disorders, or significant heart disease going through more invasive procedures. Relevant specialist's e.g. a geriatrician should be consulted whenever in doubt how to provide best practice of care. Generally, adjustment of drug selection and dosage is required for the elderly. Elderly patients are generally more sensitive to analgesics and sedatives. As polypharmacy is frequent, one should be aware of potential interactions. The variability in pharmacodynamics and kinetics is high; usually, smaller doses are needed for clinical effect compared to the adult population, and the duration of action is prolonged. Therefore dosing should be carefully titrated by the principle: “start low – go slow”. Using local anesthetics for elderly is usually safe. Not different from other adults, clinicians should be aware of allergies, decreased liver and kidney function, and pay attention to correct dosing of local anesthetics to prevent toxic reactions.