Note: The specific book Objective Anaesthesia Review by Kulkarni & Patil is not in the library database. However, the content below is compiled from Miller's Anesthesia 10th Edition (Chapter 61: Geriatric Anesthesia) and Morgan & Mikhail's Clinical Anesthesiology 7th Edition (Chapter 43) - the two most authoritative and MCQ-exam-relevant sources covering the same geriatric anesthesia curriculum. This will cover all the topics that the Kulkarni-Patil objective book draws from.

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GERIATRIC ANESTHESIA - COMPREHENSIVE EXAM REVIEW NOTE

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1. DEFINITIONS

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2. AGE-RELATED PHYSIOLOGIC CHANGES (SYSTEM-WISE)

A. CENTRAL NERVOUS SYSTEM (CNS)

• MCI (Mild Cognitive Impairment): Objective cognitive decline but no impairment in daily activities; precursor to dementia; 10-20% prevalence in >65 yrs
• Depression: 7.7% in geriatric primary care; ~20% in MCI patients; associated with delirium, MACE, increased analgesic use

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B. CARDIOVASCULAR SYSTEM

• Resting systolic cardiac function is PRESERVED even in octogenarians (in absence of disease)
• Increased vagal tone + decreased adrenergic receptor sensitivity → reduced HR
• Geriatric patients are preload-dependent and depend on atrial kick for cardiac output
• Atrial fibrillation or any arrhythmia → loss of atrial kick → significant CO drop
• Diastolic dysfunction is the predominant age-related cardiac change, NOT systolic dysfunction
• E/E' ratio >15 = diastolic dysfunction; E/E' <8 = normal diastolic function (echocardiography)
• Prolonged circulation time → delayed onset of IV drugs BUT speeds inhalational induction

• Blunted baroreceptors
• Decreased vascular compliance
• Diastolic dysfunction (preload sensitive)
• Prolonged circulation time

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C. RESPIRATORY SYSTEM

• Closing capacity (CC) > FRC: At age 45 in SUPINE position; at age 65 in SITTING position
• This means small airway closure occurs during normal tidal breathing in supine elderly patients → V/Q mismatch → hypoxemia
• FRC increases, FVC decreases - this is the key spirometric pattern
• Blunted responses to hypoxia and hypercapnia = major risk for postoperative respiratory depression
• Opioids especially dangerous because of blunted chemoreceptor response

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D. RENAL SYSTEM

• Normal serum creatinine does NOT mean normal renal function in elderly - use CrCl or eGFR
• Impaired Na+ handling → susceptible to both dehydration AND fluid overload
• Reduced drug excretion → prolonged drug action (NMBDs, opioids, etc.)

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E. HEPATIC SYSTEM

• Phase I (oxidation, reduction, hydroxylation) decreases more than Phase II (conjugation, glucuronidation)
• Decreased albumin → increased free fraction of warfarin, phenytoin, benzodiazepines, propofol

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F. MUSCULOSKELETAL SYSTEM

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G. ENDOCRINE/METABOLIC

• Decreased thermoregulation → prone to hypothermia
• Neuroendocrine stress response: largely preserved or only slightly decreased in healthy elderly
• Basal metabolic rate: decreases
• Insulin resistance: increases

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3. PHARMACOLOGY IN GERIATRIC PATIENTS

A. Pharmacokinetic Changes

B. Pharmacodynamic Changes

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4. PREOPERATIVE ASSESSMENT

Essential Preoperative Tests (ACS/AGS Guidelines)

Cardiovascular Preoperative Evaluation

• Follow AHA/ACC guidelines for cardiac risk stratification
• Specific concern: diastolic dysfunction - more common than systolic in elderly
• E/E' > 15: Diastolic dysfunction (elevated LVEDP)
• E/E' < 8: Normal diastolic function

Cognitive Screening Tools

• MMSE (Mini-Mental State Examination)
• MoCA (Montreal Cognitive Assessment): More sensitive for MCI
• TICS (Telephone Interview for Cognitive Status): Score < 30 = impaired
• Clock Drawing Test
• Cognitive impairment is the most consistent risk factor for postoperative delirium

Frailty Assessment

• Fried Frailty Phenotype (gold standard but needs trained staff):
  • Unintentional weight loss
  • Exhaustion
  • Low physical activity
  • Slow gait speed
  • Weak grip strength
  • 3-5 criteria = frail; 1-2 = pre-frail
• Clinical Frailty Scale (CFS): 1-9 scale; validated, easy to use
• Frailty is a powerful predictor of postoperative morbidity and mortality

Potentially Inappropriate Medications in Elderly (Beers Criteria - Perioperative)

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5. INTRAOPERATIVE MANAGEMENT

General Anesthesia Considerations

1. Induction:
   • Use reduced doses of all induction agents (30-50% reduction)
   • Propofol: exaggerated hypotension - give slowly, in small increments
   • Pre-oxygenation is vital (reduced FRC, low PaO2)
   • Rapid desaturation during apnea (increased CC/FRC mismatch)
2. Airway:
   • Edentulous patients: mask fit may be difficult
   • Atlantoaxial instability risk (especially RA patients)
   • Kyphosis/kyphoscoliosis → difficult intubation positioning
   • Risk of aspiration: ↓ lower esophageal sphincter tone, ↓ gastric motility
3. Maintenance:
   • Reduced MAC (volatile agents)
   • Avoid Beers criteria drugs
   • Use processed EEG monitoring (BIS) to guide depth - may reduce POCD/delirium
   • Maintain normothermia (very prone to hypothermia)
4. Hemodynamics:
   • "Rollercoaster" BP common - initial hypotension then hypertension on laryngoscopy
   • Subtrochanteric fractures: >1 L occult blood loss possible → exaggerated propofol hypotension
   • Avoid sustained hypotension or hypertension (both increase myocardial ischemia risk)
   • Maintain euvolemia carefully (diastolic dysfunction = preload sensitive)
5. NMBDs:
   • Prefer cisatracurium (Hofmann elimination, no organ dependence)
   • Use neuromuscular monitoring (TOF)
   • Ensure full reversal before extubation
   • Sugammadex preferred for rocuronium/vecuronium reversal

Regional Anesthesia Considerations

• Lower incidence of postoperative thromboembolism (peripheral vasodilation maintains venous flow)
• Better respiratory function maintenance (unless high block reaching intercostals)
• Less cognitive dysfunction (debated)
• For hip surgery: lower DVT/PE incidence

• Obscured spinal landmarks (vertebral degeneration)
• Difficult positioning (fracture pain)
• Calcified ligaments → may need different needle angle/force

• Hypobaric or isobaric spinal - to avoid having patient lie on fracture side
• Post-dural puncture headache (PDPH): LESS common in elderly (lower CSF pressure, less dural elasticity)
• Spinal spread: Greater spread in elderly (decreased CSF volume, increased leptomeningeal permeability, kyphosis)
• Epidural dose: Reduce dose (less epidural fat volume, venous engorgement in vertebral column)

• Studies conflict on mortality advantage of regional over general
• Regional preferred for: DVT prevention, respiratory compromise patients

Choice of Anesthesia: General vs. Regional

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6. POSTOPERATIVE MANAGEMENT

Postoperative Cognitive Dysfunction (POCD)

Postoperative Delirium (POD)

• Education of healthcare professionals about delirium
• Multicomponent nonpharmacologic interventions:
  • Daily physical activity
  • Cognitive reorientation
  • Bedside family presence
  • Sleep enhancement (nonpharmacologic sleep protocol)
  • Early mobility / physical rehabilitation
  • Adaptations for visual and hearing impairment
  • Adequate nutrition and fluid repletion
  • Pain management
  • Appropriate medication usage (avoid Beers criteria drugs)
  • Adequate oxygenation
  • Prevention of constipation
  • Minimize patient "tethers" (Foley catheters, ECG leads, SCDs)

• Haloperidol: traditional agent (but Beers criteria caution - use only if severe agitation)
• Dexmedetomidine: increasingly preferred for prevention/treatment in ICU
• Avoid benzodiazepines (worsen delirium, except in alcohol withdrawal)

Electrolyte Abnormalities (Preoperative Concern)

• Sodium < 130 or > 150 mmol/L
• Potassium < 3.0 or > 6.0 mmol/L
• Glucose < 60 or > 300 mg/dL
• All of these significantly increase perioperative risk

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7. PAIN MANAGEMENT IN ELDERLY

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8. TEMPERATURE REGULATION

• Hypothermia much more common in elderly
• Decreased basal metabolic rate
• Decreased shivering response
• Decreased peripheral vasoconstriction
• Decreased insulating subcutaneous fat
• Active warming mandatory (forced air warming, warm IV fluids)
• Perioperative hypothermia → coagulopathy, surgical site infection, cardiac events

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9. SPECIFIC SYNDROMES IN GERIATRIC ANESTHESIA

Frailty

• Fried phenotype: 5 criteria (weight loss, exhaustion, low activity, slow gait, weak grip)
• Frail = 3-5 criteria; Pre-frail = 1-2
• Strong independent predictor of surgical mortality

Sarcopenia

• Loss of muscle mass and strength
• Reduced drug volume of distribution for hydrophilic drugs
• Higher plasma concentration with standard doses
• Increased fall risk, prolonged recovery

Polypharmacy

• 5 medications = polypharmacy

• Very common in elderly
• Risk: drug-drug interactions, drug-disease interactions
• Review ALL medications preoperatively
• Continue: antihypertensives, beta-blockers, statins, antiepileptics, antidepressants
• Hold: ACEi/ARBs on day of surgery (risk of refractory hypotension), metformin (lactic acidosis if contrast/renal impairment)

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10. DNR ORDERS IN THE PERIOPERATIVE PERIOD

• Both ACS and ASA oppose automatic suspension of DNR orders during surgery
• Favor "Required Reconsideration" - surgeon and anesthesiologist discuss with patient preoperatively
• Discuss: what resuscitative measures patient would accept intraoperatively
• Patient may choose limited resuscitation (specific procedures only, context-specific)

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11. HIGH-YIELD MCQ FACTS SUMMARY

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12. QUICK RECALL: ORGAN SYSTEM CHANGES AT A GLANCE

CNS:       ↓ brain mass, ↓ MAC, ↓ CBF, ↓ neurotransmitters
CVS:       LVH, ↓ compliance, diastolic dysfunction, preserved LVEF
            ↓ HR max, ↓ baroreflex, ↑ SBP, wide pulse pressure
RESP:      ↑ RV, ↑ FRC, ↑ CC, ↓ FVC/FEV1, ↓ PaO2, ↓ responses
RENAL:     ↓ GFR, ↓ tubular function, ↓ drug clearance
LIVER:     ↓ mass, ↓ blood flow, ↓ Phase I > Phase II metabolism
MSK:       ↓ muscle, ↓ bone density, kyphosis, ↓ TBW
ENDO:      ↓ thermoregulation, ↑ insulin resistance
PHARMA:    ↓ MAC, ↓ induction doses, ↑ Vd lipophilic, ↓ Vd hydrophilic
            ↑ sensitivity all CNS drugs, prolonged NMBDs

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