Chandra M. Kumar

Anaesthesia for ophthalmic surgery has always been challenging because the patients range across all ages, but the elderly are especially vulnerable. They have an increased morbidity and are often taking multiple drugs that make even anaesthesia for minor surgery more risky. No wonder there has been a shift in the delivery of anaesthesia towards regional techniques although general anaesthesia remains the technique of choice for many intermediate and most complex ophthalmic operations. Understanding the physiology of the eye, the relevant anatomy, and the ophthalmic drugs patients may receive, all have major influences on the choice of anaesthesia. This varies worldwide but the current preference is firmly in favour of local anaesthesia. A practising ophthalmic anaesthetist should be skilled in a range of different techniques to deal with the needs of different operations, operators, and, most importantly, patients.

Arthritis and falls are common in the elderly and hence lead to major bone and joint surgery. Elderly patients may suffer from significant cardiorespiratory, renal, and neurologic dysfunction, and they may be malnourished; therefore, preoperative assessment is essential. Both general and regional anaesthesia techniques are commonly used, but regional anaesthesia, with or without sedation, is preferred. The use of cement during surgery is known to be associated with intraoperative morbidities, as is the use of a tourniquet. Antibiotics are routinely used, but they must be administered before the tourniquet is inflated. The incidence of deep vein thrombosis and pulmonary embolism is high, and prophylaxis should be considered. Blood loss may be excessive, especially during revision surgery; measures should be taken to minimize blood loss. Regional technique, with or without opioids, provides good analgesia. Patient-controlled analgesia (PCA) with an opioid remains a useful method where possible.

The benefits to the elderly of current surgical advances are as good as or better than to younger patients. Preassessment serves to individualize operative decisions to optimize the patient’s condition and improve the outcome. These processes require experienced surgical and anaesthetic input. General patient factors are detailed, including communication skills, behavioural adaptation, functional reserve, cognitive function, and frailty. Systematic comorbidities, such as cardiovascular, neurological, respiratory, renal and nutritional status are discussed. The risk/benefit of the proposed procedure, which is often assessed using risk-stratification systems, is reviewed. Time to full recovery and the duration of convalescence are identified as lacking appropriate data at present. Finally, the emerging data on active, multidisciplinary ‘prehabilitation’ before surgery to improve and optimize the general fitness, chronic disease states, and medication of elderly patients in the weeks before elective surgery are examined.

The increasing provision of neurosurgery to the elderly is reviewed in this chapter. The two major areas of practice and the forms of presentation are briefly discussed. Specific issues with the elderly neurosurgical patient are then considered, including the urgency of the surgery, surgery duration, extent of the planned procedure, and management of concurrent drug therapy. Details on the common risks with hyperventilation and hypothermia are noted, and the use of more recent anaesthetic agents, remifentanil and desflurane, is covered. Spinal surgery for decompression and stabilization for cervical, odontoid, and lumbar regions, as well as the common risks and complications are discussed. Both vertebrectomy and vertebroplasty are reviewed. Intracranial surgery, usually for decompression because of tumour or haematoma, is discussed, including the recent aggressive treatment of haemorrhagic stroke. An overview of the developing field of stem cell implantation and stereotactic ablative surgery completes the chapter.

Emergency surgery in the elderly is needed even if elective surgery would not be considered. Often, it is due to trauma or to intra-abdominal, vascular, or neurosurgical emergencies. The time from onset of the cause of the emergency to operative treatment is directly related to complications and death. Delay to accurate diagnosis is common and may be masked by delirium. Sepsis, pain hypotension, and metabolic disorders may all trigger delirium. Resuscitation and optimization should be concurrent with operative management. Important factors considered include the possible cause of a fall (cardiac/neurologic), likelihood of severe hypovolaemia, electrolyte disorders, and ischaemic vascular disease (occlusive and embolic). Emergency laparotomy is reviewed with the possible reasons behind the appalling outcome data, such as delayed diagnosis and poor nutritional state.

Successful outcome from day surgery depends on good preoperative preparation, education of patients, day-surgery pathways, informed decisions regarding planned procedures, and postoperative care. Day surgery is widely accepted as the default position for the vast majority of patients requiring surgery, with inpatient stay chosen only by exclusion. Day surgery remains a good choice in the elderly, subject to appropriate home care after surgery. Patients should be assessed sufficiently ahead of the surgery to allow preparation, management of associated chronic diseases, and optimization. General anaesthesia may be associated with higher incidence of postoperative cognitive dysfunction, and it should be avoided as much as possible. Regional anaesthesia is the preferred choice when applicable because it provides good postoperative analgesia. Spinal anaesthesia is useful, but it can be associated with delayed discharge. A multimodal approach to pain relief and management of postoperative nausea and vomiting (PONV) are essential because inadequate management can significantly delay discharge.

There are many reasons for delayed recovery, but, usually, it is due to residual effects of anaesthetic agents/premedication. There are guidelines for recognizing and managing these cases. Emergence delirium may be dangerous, and it should be recognized and treated as an emergency. Elderly patients may have impaired hearing and vision. Spectacles and hearing aids should be given back to them as soon as possible in the recovery area to limit disorientation. Pain and its intensity may be difficult to recognize and quantify in the elderly. Increased inter-individual variability in the elderly means that titration to effect rather than a fixed dosage is essential, and when the mental status of the patient allows it, patient-controlled analgesia (PCA) is quite appropriate.

The impact of the ageing population across the world is reviewed. Aging, migration, and dependency are discussed, as is the likely cost, both social and financial, in providing care to dependent elderly patients. Dependency ratios and population pyramids are used to illustrate the scale and variation of the population changes. Advances in surgical and anaesthetic practice and their effects on day-care surgery are outlined. The utility of risk indices and prehabilitation in optimizing the elderly surgical patient is explored. The political and social dimensions of providing high-quality care to an increasingly old population are discussed. The financial pressures and the increasing complexity and expense of newer therapies are challenging, and comprehensive state-funded delivery currently appears unsustainable. Finally, the impact of the changes in the expectations of the ‘baby boomers’ generation, as they age, and in relation to their increasing use of the Internet and social media, are reviewed.

Age is not an independent predictor for poor outcome from intensive care. This chapter reviews admission criteria for the elderly and the assessment of likely outcome including the differences between traumatic or surgical admissions against medical ones. Pre-existing comorbidities all limit functional recovery, and only about 60% of elderly patients get back to their preadmission level of activity, although this may not detract from their perceived quality of life. Potential bias in the use of quality-of-life measures by clinical staff is discussed. Information on the identification of futility and the move to either palliation or withdrawal of support is discussed. Complications are common in the intensive-care patient population, and the reasons that they may be irreversible in the elderly are reviewed. The limitation of care, the use of advanced directives, and the assessment of legal capacity are reviewed.

This book provides a timely and authoritative synopsis of the current state of anaesthesia and the elderly patient at a time when the challenge of caring for the growing numbers of elderly patients is probably the greatest faced by healthcare across the globe. The book reviews important developments in the understanding of clinical practice serving the elderly. It describes the need for anaesthesia to deliver ‘best care’ to the elderly, with the aim to maintain their independent living. It then details the key features of ageing and the effect these have on physiology and pharmacology. Specific aspects of practice, including preoperative assessment; day surgery; emergency surgery; anaesthesia for orthopaedic, urological, and gynaecological surgery, as well as major abdominal surgery; neurosurgery; and critical care. Emphasis is placed on managing postoperative care and cognitive dysfunction (POCD), with additional discussion of ethical issues and the law pertaining to the elderly patient. A new chapter reviews the challenges of treating elderly patients in non-theatre environments.