Editorial article
Anesthesia in the elderly patient. Resilience in frailty time
Anestesia en el paciente anciano. Resiliencia en tiempos de fragilidad
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Resilience in frailty time" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "486" "paginaFinal" => "488" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Manuel Á. Gómez-Ríos, Alfredo Abad-Gurumeta" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Manuel Á." "apellidos" => "Gómez-Ríos" "email" => array:1 [ 0 => "magoris@hotmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Alfredo" "apellidos" => "Abad-Gurumeta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Anesthesiology and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Spanish Difficult Airway Group (GEVAD), A Coruña, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Anaesthesiology and Perioperative Medicine, Hospital Universitario Infanta Leonor, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Anestesia en el paciente anciano. Resiliencia en tiempos de fragilidad" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">“The oak fought the wind and was broken, the willow bent when it must and survived”</span></p><p id="par0010" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Robert Jordan, The Fires of Heaven</span></p><p id="par0015" class="elsevierStylePara elsevierViewall">The term "resilience" refers to the ability to resist deformation pressure, bend flexibly and return to its original shape. This concept could have 2 meanings for the elderly patient in perioperative medicine. The first, and most relevant, is the ability to successfully cope with surgical stress. The second is the sustainability of health systems under stress in the face of a growing ageing population.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> These, unavoidably, must adapt the resources and the care model to continue providing efficient quality care.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Ageing is characterised by a chronic systemic inflammatory state causing progressive organ deterioration<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> and reduced physiological "resilience" to stress.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> The pathophysiology of the response to surgical stress is key to designing any intervention.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Surgery, through sensory afferents and local cytokine release, activates the sympathetic-medullary-adrenal and hypothalamic-pituitary-adrenal axes, producing neuroendocrine-metabolic, hemodynamic and immuno-inflammatory changes, haemodynamic and immuno-inflammatory changes to produce energy, synthesise acute phase proteins, maintain intravascular blood volume and meet increased oxygen demand. This exaggerated hypercatabolic and hyperdynamic or sustained response compromises outcomes in patients with limited physiological reserve such as the elderly.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Postoperative outcomes are the product of the patient's preoperative situation, the degree of surgical stress triggered and the anaesthetic/surgical intervention applied.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Full recovery with maintenance of quality of life should be the primary objective and preserving brain health is the main goal of perioperative care. For this, the care of the geriatric patient must be planned individually.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Preoperative assessment and optimisation are a key element. Enhanced recovery programs have improved outcomes by attenuating the response to surgical stress. However, evidence in the elderly is limited and many outcomes remain poor,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> so efforts should be extended to the pre-operative period in order to increase resilience.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The aim of preoperative assessment is to evaluate physiological reserve, common geriatric syndromes such as frailty, cognitive impairment, sensory deficits, polypharmacy, malnutrition and limited functional capacity, and to reduce potential complications.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> Depending on resources, this is done in the pre-anaesthesia consultation or by means of a comprehensive geriatric assessment.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The current traditional preoperative assessment suffers from inefficiency in the frail elderly,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> as it focuses on immediate intra- and postoperative optimisation while neglecting long-term interventions, hinders interdisciplinary coordination causing delays, and fails to detect comorbidities and undiagnosed geriatric syndromes. An efficient model should be able to stratify risk and identify recovery indicators. This should include frailty as a core test because, unlike chronological age, it is a valuable multidimensional descriptor of vulnerability that is associated with multimorbidity and geriatric syndromes, correlates consistently with adverse medical-surgical outcomes, hospital stay and mortality,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> allows for risk-benefit balance and identifies domains to target personalised interventions maximising its cost-effectiveness. Easily applicable validated tools, such as the clinical frailty scale or the FRAIL scale, are recommended to complement the ASA classification.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> Its use, although it has shown up to 3 times higher survival, remains very limited.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">A positive assessment of frailty should be followed by a comprehensive geriatric assessment, the gold standard for the assessment and management of frailty.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,7</span></a> It is a multi-domain interdisciplinary diagnostic process, focused on determining the medical, functional, nutritional, cognitive and psychosocial status of a frail older person, in order to develop a coordinated and integrated long-term treatment and follow-up plan.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Three domains of intervention can potentially improve the prognosis of the frail patient: shared decision-making, interdisciplinary geriatric management and prehabilitation.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Identifying the degree of frailty allows: (1) predicting the impact on quality of life, function and cognition, and providing tailored information<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>; (2) setting goals and comparing them with expectations<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,9</span></a>; (3) realistic risk-benefit counselling for shared decision-making,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> and (4) personalised perioperative care to reduce the impact of surgery.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Proactive patient-centred multidisciplinary approaches involving surgeon, anaesthesiologist and geriatrician are the cornerstone for improving outcomes, especially in intermediate-high risk surgical procedures.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,8,10</span></a> However, implementation barriers limit its application.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Multimodal prehabilitation programmes of at least 4 weeks pre-procedure could improve the prognosis of frail elderly patients,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> but further evidence is required in this population to be standard practice.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The pre-operative approach, meanwhile, should be individualised and consist of interventions tailored to functional, nutritional, cognitive-psychological status and co-morbidities, with patients and families empowered to improve outcomes through a proactive approach.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Perioperative neurocognitive disorders, with devastating outcomes (delirium increases the risk of complications and mortality up to 10-fold), are the most common complication in the elderly,<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,12</span></a> which is why it is important to include a rapid screening test for cognitive impairment such as the Mini-Cog<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,13</span></a> (there is no extensively validated test in the surgical population<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>), as it allows for risk stratification, risk reporting and modification of predisposing and precipitating factors through "brain health protection" programmes, assessment of comprehension capacity to obtain informed consent and objective recording of baseline cognition to quantify new deficits.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Therefore, such screening, despite its common omission,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> should be routine practice in patients over the age of 65.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">All patients scheduled for major surgery require screening for modifiable factors such as malnutrition, sarcopenia, and anaemia, as they are key risk factors for morbidity and mortality.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Recommended preoperative tests for all older adults include haemoglobin, renal function, and albumin due to the relatively high incidence of anaemia, renal dysfunction, and malnutrition.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Other tests should only be performed if clearly indicated, as they cause unnecessary delays and costs.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The intraoperative management of the elderly patient requires an awareness of their special physiological, anatomical and pharmacological considerations.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Placement requires pressure point padding due to vulnerability to pressure ulcers and nerve and osteoarticular lesions. Monitoring follows the general criteria, with special emphasis on maintaining normothermia, since thermoregulation is compromised.</p><p id="par0095" class="elsevierStylePara elsevierViewall">To preserve cardiac output, a state of normovolemia prior to anaesthetic induction is desirable due to the preload-dependence of the elderly secondary to an impaired ®-adrenergic response. Hypovolemia can precipitate severe hypotension. Fluid therapy must be judicious to preserve tissue perfusion without causing congestive heart failure, given the reduced ventricular compliance. Acute renal failure accounts for one fifth of postoperative deaths in the elderly. The usual decreased renal reserve requires a meticulous strategy to reduce hypovolemia, intraoperative hypotension, maintain adequate electrolyte balance, and avoid nephrotoxic drugs. Mean blood pressure should be maintained within 25% of preoperative levels.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The choice of anaesthetic technique should take into account the requirements of the surgical procedure, coexisting diseases, minimising direct brain insult and physiological stress to prevent postoperative complications and patient preferences.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,8,15</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Although the evidence on the benefits of regional anaesthesia over general anaesthesia is limited, its use in the elderly patient has multiple advantages<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,8,15</span></a>: (1) decreases nociceptive afferents to the central nervous system, thus reducing the need for centrally acting drugs and systemic anaesthetic agents, (2) attenuates surgical stress to a greater extent, (3) increases haemodynamic stability and preserves spontaneous ventilation, (4) provides superior intra- and postoperative analgesia avoiding polypharmacy, drug interactions, hypoxic events and respiratory complications, (5) may reduce the incidence of postoperative neurocognitive disorders (general anaesthesia could be an independent risk factor), and 6) improves other specific outcomes (reduced need for intensive care, hospital stay, readmission rate and healthcare costs), accelerates recovery and generates greater satisfaction. Therefore, unless contraindicated, regional anaesthesia should be the main anaesthetic-analgesic approach in the elderly patient. Peripheral nerve blocks are a desirable anaesthetic alternative in this population.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> If not the primary technique, it should be used in combination as a central tool in intra- and postoperative multimodal analgesia regimens as a component of intensified recovery programmes,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> as it reduces acute pain, opioid consumption and thus the incidence of delirium<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and cognitive dysfunction, improves early mobilisation and reduces the incidence of pneumonia and healthcare costs.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Sedation should be approached with caution due to pharmacokinetic and pharmacodynamic changes leading to increased sensitivity.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Old age also predisposes to airway obstruction, respiratory depression, hypoxaemia, hypercapnia or aspiration (impaired laryngeal reflexes).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The use of benzodiazepines should be avoided, with a 2–5 times higher incidence of delirium.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,8</span></a> Dexmedetomidine is a drug of choice as it reduces the incidence of delirium by up to 50% and cognitive dysfunction due to its possible neuroprotective effect.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,17</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The elderly are particularly vulnerable to systemic anaesthetics and analgesics, especially at the cerebral level, so brain protection strategies must be implemented.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Anaesthetic requirements correlate inversely with increasing age, so the dose should generally be reduced by at least 25%.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Etomidate is the induction agent of choice in frail patients as it provides greater hemodynamic stability.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Inhalation anaesthesia with sevoflurane could be a risk factor for postoperative neurocognitive disorders compared to intravenous anaesthesia with propofol.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,19</span></a> Current evidence shows that multicomponent intervention including perioperative benzodiazepine avoidance, age-adjusted MAC, careful titration of anaesthetic depth guided by electroencephalographic monitoring<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,8</span></a> and effective pain management is the most effective strategy to minimise the risk of delirium by up to 40%.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,13</span></a> Complete reversal of neuromuscular blockade must be confirmed by neuromonitoring.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The older patient also requires close postoperative care, as up to 20% experience complications. Intensive care and prolonged hospital stay are more common.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The use of capnography makes it possible to prevent episodes of severe hypoxia and hypercapnia for the reasons stated above.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Analgesia is a critical aspect. Opioids induce delirium, but so does pain, which also causes complications such as ischemic events, pulmonary complications, or chronic pain.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Multimodal analgesia with a central role of regional techniques is recommended within an enhanced recovery programme approach.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,8</span></a> Nonsteroidal anti-inflammatory drugs and gabapentinoids should be used with caution, and meperidine, metoclopramide and anticholinergics should be avoided, as should drug interactions.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,8</span></a> Optimal analgesia promotes early mobilization, shortens hospital stay, and reduces complications.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Delirium requires immediate exclusion of hypoxia, hypotension, hypoglycaemia, and sepsis.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The first-line approach should be a non-pharmacological multi-component intervention (involving the family, mobilisation, patient reorientation, social interaction, comprehensive geriatric review, cognitive aids such as glasses and hearing aids, sleep and nutritional hygiene, noise reduction, addressing pain and other sources of discomfort), as it is the most effective in preventing and treating delirium. Benzodiazepines and antipsychotics<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> should be avoided unless the benefits outweigh the risks to patient or staff.</p><p id="par0140" class="elsevierStylePara elsevierViewall">The family must be proactive with regard to recovery. Simple mobility programmes, such as daily walking, reduce the risk of functional impairment and loss of independence.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Postoperative recovery is an active process that begins preoperatively.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The exhausted traditional management paradigm must evolve to a new model based on a collaborative multidisciplinary, patient-centred, evidence-based approach, with a comprehensive geriatric evaluation, optimization of physiological reserve and functional capacity, preoperative planning and proactive intraoperative and postoperative management, with carefully planned hospital discharge and continuity of care. 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