Anaesthesia for the Elderly Patient - 2nd Edition
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Contents
Preface to the second edition vii
Preface to the first edition ix
Definitions, social trends, and epidemiology 1
2 Pathophysiological changes of ageing and their relevance to anaesthesia 13
3 Anaesthetic pharmacology in the elderly 29
4 Preoperative assessment and preparation of elderly patients
undergoing major surgery 43
5 Day-case anaesthesia in the elderly 53
6 Emergency anaesthesia in the elderly 59
7 Anaesthesia for orthopaedic surgery in the elderly 63
8 Anaesthesia for major abdominal surgery in the elderly 77
9 Neurosurgery in the elderly 89
0 Urological and gynaecological surgery in the elderly 97
Postoperative care and analgesia 105
2 Intensive care and the elderly 117
3 Anaesthesia for non-theatre environments 125
4 Cognitive dysfunction and sleep disorders 137
5 Ethics and the law involving the elderly 149
Index 57
Preface to the second edition
In the nearly 0 years since we wrote the first edition of this book, the predictions
about the effect an ageing population would have on society, states, and medicine
are now clearly present across the world. The challenges of providing the best
care to these vulnerable individuals and paying for that care are central to policy
making and planning of most national governments, as well as in health care insti-
tutions and medical bodies. Many models are being proposed; however, none yet
appears without serious flaws.
It remains true that, at present, the elderly consume a disproportionate share
of health care provision, but when delivered well, health care maintains their inde-
pendence in society, and that more than balances the alternative cost of providing
personal care to dependent patients, their relatives, carers, and the state. It is also
worth remembering that they have contributed to national healthcare funds for
their entire working lives.
There has been an increase in the number and quality of research papers in
anaesthesia and critical care relating to or including elderly patients, as well as a
handful of major textbooks on the subject. Preventing cognitive decline is of the
highest priority, with dementia care in the UK costing more than £26 billion/year.
Research funding bodies have therefore given priority to research into cognitive
dysfunction, and major collaborations are starting to unravel possible mechanisms
for its causation. National audits of outcome are more widespread, for instance,
those for fractured neck of the femur and colorectal surgery, and the results are
informing government policy making.
In response to this, we have updated all of the book’s chapters, some of which
have been completely rewritten. For example, we added a new chapter on non-
theatre-based anaesthesia. Yet we aimed to retain the principle of the first edi-
tion: namely, to present current information on the care of the elderly anaesthetic
patient, in an accessible and easy to understand format. As before, we hope this
readily accessible source of information will support anaesthetists, intensivists,
and other clinicians caring for elderly patients. We hope it will generate their
enthusiasm to read further and develop into leaders in this highly rewarding field
of practice.
Chris Dodds
Chandra M. Kumar
Frédérique Servin
Preface to the first edition
For the first time in recorded history, there are more people over the age of
65 years than under the age of 6. Associated with this is an increased longevity
resulting in more people than ever reaching their ninth decade or more. These
people are much more likely to need access to the highest-quality healthcare.
Unfortunately, they also suffer the highest rate of complications, including death.
In some, this is part of an end-of-life process, but for others, this precipitates
them into many years of dependence on others, including admission into nursing
care despite full independence before becoming ill.
The challenges that elderly patients pose to anaesthetists and intensivists are
greater than for any other group of patients, and yet the entire field remains one
of the most poorly researched aspects of medical care.
The aim of this handbook is to provide rapid access to information that will help
clinical staff understand some of the problems that occur in caring for the elderly
patient. Basic physiological changes and the pharmacological variations with age-
ing inform the later chapters on the common areas where elderly patients are
most likely to present. There are chapters dealing with the commonly occurring
presentations of elderly patients, such as emergency surgery and elective ortho-
paedic, urological, abdominal, and neurological surgery.
A brief review of ethics and current law relating to the elderly and anaesthesia
has been included to help with understanding the issues of capacity and consent,
both of which are areas where the elderly are more likely than younger patients
are to require careful assessment and management.
It is hoped that this handbook will not only provide this information in an acces-
sible format but also encourage readers to seek more information on the care of
elderly patients, and indeed research into their needs so that we can improve the
delivery of effective care for them.
Chris Dodds
chapter 1
Definitions, social trends,
and epidemiology
Key points
• The proportion of the elderly in the population is increasing.
• There are now more people over the age of 65 than under the age of 6.
• Aged economies (where more capital is spent on elderly than on younger
groups) will quadruple in the next 40 years
• Dependency increases with advancing age.
• The social and financial costs of dependency are staggeringly large.
• Elderly cohorts differ markedly—research has a ‘sell-by’ date.
• Social changes, such as independent living, have a major influence of health care
provision.
• Life expectancy is increasing.
• Technological advances will need to play a major part in the delivery of care to
the elderly.
• Anaesthesia has an important role in maintaining independence.
1.1 Social influences
The changes in population demography are relatively uniform across the world,
but these are for differing reasons. Demographic studies show a proportionate
increase in the number of the elderly and a decline in numbers of the younger
members of society. This may be due to either a prolonged survival or a falling
birth rate in the so-called developed countries or a loss of young adults from
infectious disease or warfare in other countries. This loss of the ‘earning classes’
has a great effect on the finances available to support the health care requirements
of an ageing population. It is usually described as a dependency ratio, where the
population over retirement age (usually over 65 years of age) is factored against
the group in active employment (usually 8–64 years of age) (Fig. .).
A more useful ratio is that of the population with a less than 5-years life
expectancy against all those over 20 with a greater than 5-years life expectancy,
the Prospective Old Age Dependency Ratio (Fig. .2)
The proportion of ‘old’ (over 60) and ‘oldest old’ (over 80) will nearly double
over the next 40 years (Table .). The only realistic future is for those over
chapter 1
Conventional old-age dependency
ratio as projected for 2030
more than 48%
38 to 47.9%
28 to 37.9%
less than 27.9%
no data
Fig. . Conventional old-age dependency ration as projected for 2030
Reproduced from European demographic data sheet 202. Vienna Institute of Demography, Vienna 202.
Prospective old-age dependency
ratio as projected for 2030
more than 28%
23 to 27.9%
18 to 22.9%
less than 17.9%
no data
Prospective old-age dependency
ratio is defined as the number
of people in age groups with
life expectancies of 15 or fewer
years, divided by the number of
people at least 20 years old in
age groups with life expectancies
greater than 15 years.
Fig. .2 Perspective old-age dependency ration as projected for 2030
Reproduced from European demographic data sheet 202., Vienna Institute of Demography, Vienna 202.
4 • definitions, social trends, and epidemiology
Table . Global ageing indicators
Life expectancy 20/2 2050 projection
Life expectancy at birth by sex (men/women) 67./7.6 73.2/78.0
Life expectancy at 60 by sex (men/women) 8.5/2.6 20.9/24.2
Life expectancy at 80 by sex (men/women) 7./8.5 8.3/9.8
Population
Number of persons aged 60+ 809,742,889 2,03,337,00
Number of persons aged 80+ 4,479,66 402,467,303
Number of persons aged 00+ 36,600 3,224,400
Percentage of persons aged 60+ .5 2.8
Percentage of persons aged 80+ .6 4.3
Sex ratio: number of men aged 60+ per 00 83.7 86.4
women aged 60+
Reproduced from Ageing in the Twenty-First Century, ‘Setting the Scene’, Copyright © United
Nations Population Fund (UNFPA) and HelpAge International, 2012.. Data from UNDESA,
Population Division (2012). Prepared by the Population and Development Section on the basis
of data from UNDESA, World Population Prospects. The 2010 Revision (New York, 2011) and
UNDEA, World Population Ageing and Development, 2012 Wall Chart (2012 forthcoming)
www.unpopulation.org, and UNDESA, Population Diversion, World Population Ageing: Profiles of
Ageing, 2011 (New York, 2011), CD-ROM
the current retirement age to remain in employment for longer. This will partly
compensate for the increasing cost of healthcare provision, but it emphasizes the
necessity to maintain these elderly people as independent and healthy.
Migration, both internal and international, is a further social influence. The elderly
may move to rural areas for retirement just as younger people leave for urban areas
(See Fig. .3). At a local level, this may lead to great regional instability in the ability
to fund the infrastructure necessary to maintain that population: roads, emergency
services, and hospitals, for instance.
The loss of an individual’s independence (Fig. .4), causes difficulties for those
who may also need to be cared for after injury or illness. Several generations may
be affected, as older parents require care at the same time as young children. Loss
of earnings may be inevitable as increasing dependency outstrips the local provi-
sion of free home-based care, further limiting care options. For most families the
cost of nursing care far exceeds the state provided funding.
The properties of the ‘elderly’ also change from one cohort to the next
because of differences in nutrition or exposure to infection, for example. These
differences make direct extrapolation of data from one group to the next difficult.
There is effectively a ‘sell-by’ date on these studies.
What information is available on the impact of major surgery in the elderly
patient population suggests that they have outcomes that are less favourable and
chapter 1
social influences • 5
25%
20
15
10
0 10.9% 9.7% 19.1% 22.9% 7.7% 8.2%
World Developed Developing
regions regions
Urban Rural
Fig. .3 Percentage of the population aged 60 or over in rural and urban areas in 2005
Reproduced from Ageing in the twenty-first century, ‘Setting the scene’. Copyright UNFPA. Data from
UNDESA, World Population Ageing: Profiles of Ageing 20 (Geneva 20), CD-ROM).
more complications compared with younger groups. Recovery is also prolonged,
and it may not allow a return to their previous level of activity. Dependency
increases with age, and it is estimated that more than 60% of the elderly will be
dependent during the last year of life. The cost to carers in the UK is estimated to
be £36 billion/year in direct and indirect costs.
Many of the interventions necessary during surgery, anaesthesia, and
intensive care that are apparently well tolerated by younger patients cause
significant problems in the elderly. These range from the minor (communica-
tion difficulties in terminology) to the major (cognitive impairment or loss of
independence).
Progressive variation in the pathophysiological make-up of patients is associ-
ated with getting older (see Chapter 2). They become increasingly individualized
in their responses to challenges. This means that the delivery of a standard pat-
tern of care often has unpredictable results.
Legislation in the UK in the form of the Mental Capacity Act 2005 defines
mechanisms for dealing with informed consent and legal capacity in patients with
impaired cognition. The full effect of these measures is still developing, although
there is much useful information on the Department of Justice website. http://
www.justice.gov.uk/downloads/publications/moj/200/Memorandum-Justice-
Select-Committee.pdf
chapter 1
Men
80%
70
60
50
40 58%
30
20 29%
20%
10
16%
0 11% 9%
World Developed Developing
countries countries
Women
80%
70
60
50 37%
40
30
22%
20
33% 16%
10
19%
0 10%
World Developed Developing
countries countries
Living with spouse only Living alone
Fig. .4 Percentage of people aged 60 or over living independently (alone or with a spouse
only), latest available data
Reproduced from Ageing in the Twenty-First Century, ‘Setting the Scene’, Copyright UNFPA. Data from
UNDESA, World Population Ageing 2011 (2012; forthcoming) based on the UNDESA Population
Division medium projection scenario World Population Prospects. The 2010 Revision
Note: the group of “developed countries” corresponds to the “ more developed regions” of the World
Population Prospects: The 2010 Revision, and the group “developing countries” corresponds to the
“Less developed regions” of the same publication.
recent advances • 7
120 millions
100
80
60
40
20
0
2010 2020 2030 2040 2050
Low-and middle-income countries High-income countries
Fig. .5 Growth in numbers of people with dementia in high-, middle-, and low-income
countries
Reprinted from Dementia: A Public Health Priority, p 19. Copyright (2012) with permission from World
Health Organisation and Alzheimer’s Diseases International
There are over 250,000 Powers of Attorney registered in the UK.
The predicted fourfold increase in numbers of patients with Alzheimer’s dis-
ease by 2050 worldwide means that we will face this problem much more fre-
quently, especially in acute situations (Fig. .5).
1.2 Recent advances
Basic science research into the causes of ageing are leading some exponents
to the belief that longevity could be increased to over 000 years—a race of
‘immortals’ being developed as we identify genetic influences involved in malig-
nancy, predisposition to disease, and ageing itself. We do not appear to have
reached that stage yet, but it is clearly a possibility (Fig. .6).
Further, preoperative assessment at some time distant from surgery has become
established, but it has problems with detecting acute changes in the elderly, and it
provides only a limited ability to improve the condition of the patient if a problem
is detected close to the time of surgery. Specific testing protocols for major sur-
gery using markers of performance, such as the move of cardiopulmonary exer-
cise testing, from being a largely cardiology-based investigation, into anaesthetic
screening, are showing some promise in risk stratification, as are the benefits of
graded exercise programmes.
chapter 1
8 • definitions, social trends, and epidemiology
Anaesthesia in the elderly
100 Modern
Percentage survival
80
Roman Victorian
60
40
20 Ancient
0
0 10 20 30 40 50 60 70 80 90 100
Age (years)
Fig. .6 Survival curves over time
Reproduced from Davenport H.T., Anaesthesia and the aged patient. Copyright (988), with permission
from John Wiley & Sons.
At another level, the growing understanding that the impact of injury has on
astrocytes and microglial cells and the role of the inflammatory response to sur-
gery is starting to illuminate the possible processes that may lead to devastating
but unpredictable postoperative cognitive dysfunction. At the same time, there
is also a debate developing on whether volatile or intravenous anaesthetic agents
provide benefits or pose risks to patients.
Clinically, there have been advances in our understanding of perioperative
management that may make for better outcomes in the elderly. For instance,
tight glycaemic control during the perioperative period improves outcomes and
reduces complication rates after surgery.
1.3 Novel procedures
Improvement in the success rates of experimental surgery for stem cell implanta-
tion means that it is likely to be of clinical utility within the next few years. The
potential to restore or maintain function in degenerative diseases has huge cost
implications for the state and for families. They range from chondrocyte resurfac-
ing in major joints instead of prosthetic replacement, replacement myocardium
to repair damage caused by infarction, or stereotactic neurosurgical placement of
stem cells into the brain to replace key cell lines, such as dopaminergic neurones
for Parkinson’s disease or cholinergic neurones for dementia.
The ability to maintain independence alone makes these attempts worthwhile.
However, given the cost benefit to both the patient and the state, these are not
going to be inexpensive procedures.
Interventional radiology has been the fastest growing speciality in medicine.
It has revolutionized many procedures that were once solely the domain of the
chapter 1
health care and political issues • 9
surgeon (see Chapter 3). Interventional cardiology has largely replaced coro-
nary artery bypass surgery as first-line management of coronary arterial stenosis.
The same technology could allow direct injection of chemotherapy directly into
the arterial supply of tumours rather than the whole patient, thus reducing opera-
tive surgery for malignancy.
Further, newer drugs are changing the face of disease presentation. Statins
have deferred the onset of ischaemic heart disease, but not the process—this
will mean an increasingly large number of elderly patients presenting with heart
disease as a new problem. This will have an effect on our screening of patients,
as they will rightly say they have no cardiovascular disease but will have organ-
specific disease, as well as the normal changes of ageing.
1.4 Risk indices
One of the most common methods used to try to quantitate the likelihood of a
particular operation being of benefit to a patient, or of assessing the risks (mor-
bidity or death), is a calculation of a ‘risk index’. The most common method used
to test the discriminating power of an index is the ‘receiver operating character-
istic’ curve. This plots true-positive predictions (sensitivity) against false-positive
predictions (specificity). The nearer to unity the area under the curve is, the bet-
ter model it is. Values above 0.704 are clinically acceptable, whereas pure chance
gives a value of 0.5 (Fig. .7).
These indices have been developed in many countries and can be used in such
areas as intensive care medicine (Apache III), major vascular surgery, and even
in day-case surgery. They all have problems in common. The development of
a risk index for one population is rarely so predictive in another group because
of genetic and environmental impacts related to each group. Extrapolation of
a group data set into individual patient outcome is also of limited value. Even
large-scale, multivariate indices, such as those used in risk stratification for car-
diac (euroSCORE) or colorectal carcinoma surgery (CR-POSSUM), are of limited
predictive value in absolute terms.
1.5 Health care and political issues
Within each health care system, there are limits on the funding available, and the
differing priorities are given to that available money. Some of the influences will
be related to geographical or social concerns: for example, the need for long-
distance transfers in remote country areas or the political aspirations of the gov-
ernment. However, keeping pace with developments in medical practice across
the broad range of specialities is impossible through state provision alone.
One aspect of this is the ‘lag time’ where funding to support clearly identified
methods of reducing complications rarely follows immediately. Yet the longer
it takes for their implementation, the more patients and their carers will suf-
fer avoidable increases in dependency. These methods range from such simple
chapter 1
10 • definitions, social trends, and epidemiology
(c)
0.8
(b)
0.6
Sensitivity
(a)
0.4
0.2
0.0 0.2 0.4 0.6 0.8 1.0
Specificity
(a) = area under the curve of 0.5 and a discrimination that
is no better than chance
(b) = small area under the curve and a poor discrimination
(c) = large area under the curve and a good discrimination
Fig. .7 The receiver operating characteristic (ROC) curve
Reproduced from Adam S.K. and Osborne S., Critical care nursing—science and practice. Copyright
(2005), with permission from Oxford University Press.
techniques such as active warming or the close control of fluid balance to the
provision of an appropriate number of high-dependency beds. This funding iner-
tia alone is likely actually to cost society more than the initial capital investment
to deliver these provisions.
There is a drive across the world to increase the proportion of surgery per-
formed as day-care or limited-stay surgery because it is believed to reduce com-
plications, deliver financial savings, and improve patient satisfaction. Initially the
scope of surgery offered was limited, and it often is offered to relatively young
patients. During the past decade, there has been an increase in the complexity
of surgery being performed as a ‘day case’, and limitations related to age have
largely disappeared.
Recently, concerns have arisen that day-case surgery is not without problems.
In particular, poor pain relief and cognitive dysfunction persist after such surgery.
It is likely that complications related to the extent of surgery and the triggered
stress responses will occur regardless of the place of care for that patient. Where
these are managed within an acute hospital, they can be treated rapidly, but if
they occur in the community, they may be less likely to be identified and treated
chapter 1
