Perioperative management of the older adult is complex. Anesthetic care itself is challenging, and both preoperative preparation and postoperative care for older adults assume greater importance than for young, healthy adults. Ideally, care is based on a comprehensive plan that integrates the roles of the anesthesiologist, surgeon, geriatrician, primary caregivers, and medical specialists. This chapter provides an overview of the role of the anesthesiologist and anesthesia techniques in pre-, peri-, and postoperative care of the older adult, in order to improve communication with other professionals who provide care to this vulnerable population.
Anesthesia is the art and science of controlling physiologic processes in order to permit interventions on the body that would be intolerable owing to normal compensatory mechanisms. Surgery, which involves a direct assault on body tissues, is the standard paradigm for understanding anesthesia. Anesthesiologists perform other valuable services, including sedation for less invasive procedures, management of pain syndromes, and the provision of critical care. European anesthesiologists are also actively involved in emergency care. Anesthesia is based on an understanding of homeostatic mechanisms and their manipulation. Homeostenosis, the restricted range and capacity of homeostatic mechanisms associated with aging, provides a challenge to the anesthesiologist. In order to tailor appropriate anesthesia care for an older adult, the anesthesia team must be familiar with the effects of aging on multiple organ systems, particularly the heart, lungs, and brain, and must be familiar with physiologic changes of age, such as increase in body fat, decreased glomerular filtration, and reduced hepatic blood flow, which affect anesthetic drug action and duration.
Preoperative care can take place in multiple settings and can occur briefly or over a period of time. The most important goal of preoperative assessment is not the risk assessment, but the improvement of the patient's medical status prior to surgery and planning for the recovery process. The anesthesiologist provides care in a different time frame and uses a different approach than is typical for other specialties. The chief complaint usually takes the form of a request for anesthesia services for a specific operation. The anesthesiologist uses a vertical or systems-based approach, most clearly articulated by Stanley Muravchick (Figure 36-1). As part of this approach, the anesthesiologist assigns an American Society of Anesthesiologists physical status classification (Table 36-1). The American Society of Anesthesiologists score is a clinician's tool, not a predictor of perioperative risk, because, while the American Society of Anesthesiologists score correlates broadly with outcomes, it does not incorporate age or type of operation, both significant influences on outcomes.
A. The traditional medical approach to diagnosis can be represented schematically as a series of horizontal techniques of inquiry (open bars) applied across the various organ systems (shaded bars) to consolidate data describing the status of different organs into ...