Sheila R. Barnett, M.D.
Instructor in Anesthesiology,
Harvard Medical School
Department of Anesthesiology,
Beth Israel Deaconess Medical Center,
330 Brookline Ave, East Campus, Stoneman 308,
Boston MA 02215
sbarnett@caregroup.harvard.edu
Fifty percent of all Americans over 65 will undergo a surgery
prior to death; thus it is important to understand the basic
physiological changes that occur during aging. The elderly are
a heterogeneous group and aging is not always a predictable
process. Although the preoperative assessment must be tailored
to the individual, some basic guidelines for elderly patients
are discussed in this section.
The preoperative evaluation of an elderly patient is best
accomplished several days before the surgery and ideally not
before medical information has been obtained from the surgeon
or primary care physician. An evaluation in a preanesthetic
clinic is advantageous and provides the patient with the additional
opportunity to meet with nursing and social work staff.
The anesthesiologist's assessment includes a history, physical
examination and review of the medical chart. Laboratory testing
is indicated by comorbid conditions and the type of surgery
contemplated; tests should not be performed solely because of
advanced age. A discussion about anesthetic techniques and risks
can reduce patient anxiety. The visit also provides the opportunity
to refute preconceived negative beliefs about the safety of
anesthetic techniques such as spinal and regional anesthesia.
Some specific areas and questions to be addressed during the
visit might include:
• What is the patientās mental status? Is the patient
able to answer coherently, or is the family answering for
him or her? Will regional techniques and outpatient surgery
be feasible?
• Does the patient have cardiac disease? Coronary artery
disease is prevalent in elderly patients, and it may be unrecognized
due to limited function prior to surgery. Is a prior cardiac
work-up available? Why was it performed? Is more needed?
• Assessing functional capacity - this may provide
an excellent estimate of reserve. For instance, can the patient
walk up and down stairs with and without groceries?
• Does the patient have pulmonary disease? Is he
or she short of breath in the clinic or lying flat? Document
room air oxygen saturation.
• Is the patient hypertensive? This may alter cerebral
autoregulation and require higher systemic pressure intraoperatively.
Make sure to document baseline blood pressure.
• Is the patient markedly anorexic, dehydrated or
very frail (e.g., in a wheelchair)? Or does the patient appear
young and vigorous for his or her age?
• Does the patient have an understanding of their
medications?
• Has the patient had a prior surgery? How did he
or she tolerate the anesthesia? Were there complications that
may influence the choice of the next anesthetic, such as confusion
or congestive heart failure?
Guidelines for Elderly Patients:
1. Expect interindividual variability
2. Advanced chronological age is not a contraindication
to surgery
3 Clinical presentation of disease is frequently atypical,
leading to delays and errors in diagnosis
4. Most older patients are on multiple medications and
have multiple illnesses (individuals older than 65 have on
average 3.5 medical diseases)
5 Diminished organ reserve can be unpredictable - limitations
may only become apparent during the surgery
6. A disproportionate increase in perioperative
risk may occur without adequate preoperative optimization
- adverse events are more frequent with emergency cases
7 Meticulous attention to detail can help avoid minor complications
that can rapidly escalate into major adverse events in elderly
patients
8 Impact of extrinsic factors - smoking, environment, socioeconomic,
etc. - is difficult to quantify
Bibliography:
Muravchick S. Geroanesthesia. Principles for Management
of the Elderly Patient. St. Louis: Mosby-Year Book, Inc.;
1997.
McLeskey CH, ed. Geriatric Anesthesiology. Baltimore:
Williams & Wilkins; 1997.