Anaes · Anaesthesia for the elderly and the co-morbid patient
Anaesthesia for the elderly and the co-morbid patient
Also known as Geriatric anaesthesia · Frailty · Polypharmacy · Postoperative delirium · Postoperative cognitive dysfunction · Pharmacokinetics of ageing · Comprehensive geriatric assessment · CPET in the elderly · Elderly emergency laparotomy
The elderly and the co-morbid patient is the largest and the highest-risk group in the modern operating theatre. The framework rests on the physiological changes of ageing (the loss of the homeostatic reserve in every organ system), the altered pharmacokinetics and the pharmacodynamics (the increased sensitivity and the reduced clearance), the frailty and the sarcopenia (the strongest predictor of the outcome), the polypharmacy, the preoperative assessment (the CPET and the comprehensive geriatric assessment), the individualised choice of the technique, the high-mortality elderly emergency laparotomy, and the postoperative neurocognitive disorders (the delirium and the postoperative cognitive dysfunction).
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Red flags
- The elderly patient has reduced physiological reserve and increased drug sensitivity. Halve the induction dose, titrate to effect, choose short-acting agents, and avoid long-acting sedatives and drugs with active metabolites.
- Postoperative delirium is common and harmful — minimise modifiable risks (sedatives, pain, catheters, sleep disruption).
- Frailty predicts outcome better than chronological age alone — score Clinical Frailty Scale and discuss goals of care before high-risk surgery.
- Induction hypotension is poorly tolerated — hold morning ACE/ARB in many protocols, vasopressor drawn up.
- Creatinine underestimates renal impairment in sarcopenia — dose renally cleared drugs on eGFR, not 'normal creatinine' alone.
Meet the patient
An 84-year-old woman, Clinical Frailty Scale 5, arrives at midnight for a perforated diverticulum. She takes seven medications including an ACE inhibitor and a DOAC, her creatinine is 90 but her eGFR is 38, and she has not eaten in two days. The registrar asks: what dose of propofol?[1][11]
The four questions that decide whether she survives this admission are the four every elderly anaesthetic turns on: what is her frailty score?, what is her real renal function?, what dose will her aged physiology tolerate?, and where does she go afterwards? Get those right and the technique almost looks after itself.[1]
References18ShowHide
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