O A L OXFORD ANAESTHESIA LIBRARY Anaesthesia for the Elderly Patient O A L OXFORD ANAESTHESIA LIBRARY Anaesthesia for the Elderly Patient SECOND EDITION Professor Chris Dodds Consultant Anaesthetist, (retired) Department of Anaesthesia James Cook University Hospital Middlesbrough, UK Professor Chandra M. Kumar Senior Consultant in Anaesthesia Khoo Teck Puat Hospital Yishun, Singapore Dr Frédérique Servin Surgical Intensive Care Unit, Department of Anaesthesiology, Bichat-Claude Bernard Hospital, Paris, France 1 1 Great Clarendon Street, Oxford, OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. 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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