Version July 2025
INTRODUCTION —
Older adults (≥65 years of age) account for a disproportionately large fraction of all surgical procedures performed in the United States (figure 1). Physiologic changes associated with aging and increased likelihood of comorbidities affect responses to anesthetic drugs and techniques and impact overall risk for anesthesia and surgery.
This topic will discuss strategies to provide optimal perioperative anesthetic management of older adult patients.
IMPACT OF AGE-RELATED PHYSIOLOGIC CHANGES ON ANESTHETIC CARE —
Aging is associated with a progressive loss of functional reserve in all organ systems (see "Normal aging"). Although there is considerable individual variability in the onset and extent of these changes, even the healthy older adult has reduced physiologic reserve such that organ systems may be compromised during illness and/or surgical stress.
Anesthetic care is also impacted by normal physiologic changes, which increase susceptibility to anesthetics [1,2].
Nervous system — Age-related changes in the central and peripheral nervous systems result in pharmacodynamic changes that affect responses to anesthetic agents and other medications, and also affect pain perception [3]. Changes in the central nervous system include reduced brain size and neuronal density, with widening of the sulci and ventricles. Also, regional reductions in neurotransmitters (eg, dopamine, serotonin, and acetylcholine) and neuroreceptors may occur [4].
●Pharmacodynamic sensitivity – Pharmacodynamic sensitivity increases with age for all intravenous (IV) agents that act within the central nervous system (eg, propofol, fentanyl, midazolam) [3]. For inhalation anesthetics, there are age-related decreases in the minimum alveolar concentration (MAC) at 1 atmosphere that prevents movement in 50 percent of patients exposed to a surgical incision [5]. This is due to increasing sensitivity to the effects of these anesthetic agents. In addition, vulnerability to the anticholinergic side effects of medications such as diphenhydramine, meperidine, and scopolamine may occur due to a decrease in cholinergic receptor activity [4]. (See 'Selection and dosing of anesthetic agents' below and "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Risk assessment'.)
Also, as noted below, greater drug effects are noted after repeated or continuous dosing of anesthetic agents in older patients compared with younger ones. (See 'Pharmacokinetic changes' below.)
●Decreased ventilatory responses – The normal ventilatory responses of the central nervous system to hypercapnia, and especially to hypoxemia, are diminished with age [6]. Thus, respiratory depressant effects of opioids, benzodiazepines, and volatile anesthetics are exaggerated, with further impairment of responses to hypercapnia and hypoxemia [7-9].
●Cerebrovascular changes – Cerebrovascular autoregulation is impaired, with diminished responses to blood pressure changes, as well as to hypoxemia or hypercapnia [6].
●Higher pain thresholds – Changes in the peripheral nervous system include a reduction in myelinated fibers, with potential alterations in pain perception [10,11]. Higher pain thresholds have been observed in older patients and may contribute to the delayed presentation of painful conditions such as acute appendicitis and peritonitis.
●Susceptibility to postoperative delirium – Although the mechanisms are not clear, it is known that postoperative central nervous system complications, particularly postoperative delirium and postoperative cognitive deficits, occur primarily in older patients [12]. (See 'Assessment of baseline cognitive function' below and "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies".)
Cardiovascular system — Normal changes in the older adult's cardiovascular system such as vascular stiffening and autonomic changes influence physiologic responses to anesthetic administration [6,13,14].
●Blood pressure lability – Labile intraoperative blood pressure (BP) is common in older patients. Vascular stiffening renders the vascular system less elastic, which leads to chronic hypertension. During surgery and anesthesia, intraoperative episodes of hypotension are common in the older adult due to [13,14]:
•Vasodilatory effects of most IV and inhalation anesthetic agents
•Sympatholysis after placement of a neuraxial block
•Certain surgical techniques (eg, laparoscopic insufflation of the abdomen causing reduced venous return)
●Autonomic changes – Autonomic changes in older adults are collectively referred to as the "dysautonomia of aging." Impaired beta receptor responsiveness limits the ability to increase cardiac output by increasing heart rate; thus, the patient becomes more reliant on maintaining vascular tone and preload. Significant hypotension can occur when baroreflex responsivity is compromised, particularly in patients who are hypovolemic or have underlying ventricular dysfunction.
●Left ventricular hypertrophy – Vascular changes increase impedance to left ventricular (LV) outflow, causing an increase in LV work, myocardial stiffening, and LV hypertrophy. Impairment of diastolic filling and overt diastolic dysfunction is present in approximately half of older adults who have a diagnosis of congestive heart failure [13,15-17]. Such patients are extremely dependent on the atrial contribution to filling during diastole (the "atrial kick"). Thus, even brief episodes of atrial arrhythmias during anesthesia may lead to significant hypotension. Furthermore, diastolic dysfunction increases the risk of development of pulmonary edema during fluid administration.
Older adult patients are more likely than younger ones to have undiagnosed cardiovascular pathology such as ischemic heart disease, calcific aortic stenosis, fibrosis of the cardiac conduction system with an increased incidence of atrial fibrillation or cardiac conduction abnormalities, or hypertension [6].
Respiratory system — Normal aging of the pulmonary system decreases overall pulmonary reserve due to changes that include [6,18-20]:
●Stiffening of the chest wall
●Decreased elasticity of lung parenchyma
●Increased work of breathing
●Increased compliance
●Increased closing capacity leading to small airway closure
●Increased ventilation/perfusion (V/Q) mismatch
●Reduced forced expiratory volume, vital capacity, and maximal rate of oxygen consumption
●Increased dead space
●Reduced baseline arterial oxygen tension (PaO2) due to increased alveolar-arterial gradient leading to susceptibility to hypoxemia
●Diminished ventilatory response to hypoxemia and hypercapnia
●Decreased respiratory muscle strength with impaired cough mechanism
●Impaired pharyngeal function
Also, undiagnosed chronic obstructive pulmonary disease (COPD) or obstructive sleep apnea (OSA) is more likely in older patients compared with younger ones [6].
Older adults are more susceptible to respiratory compromise during monitored anesthesia care with sedation and during the preoperative and postoperative periods. As noted above, they may have exaggerated respiratory depressant effects of opioids, benzodiazepines, and volatile inhalation agents (see 'Nervous system' above), and this increases their risk for hypercapnia, hypoxemia, apnea, and respiratory failure [7-9,21]. These risks are exacerbated if reversal of neuromuscular blocking agents (NMBAs) is inadequate, particularly in patients who are frail and more susceptible to fatigue and in those with pulmonary comorbidities. (See 'Neuromuscular blocking agents' below and 'Mortality and morbidity' below.)
Liver function — Changes in liver function due to normal aging include:
●Decreased hepatic mass and function, as well as decreased hepatic blood flow, resulting in slower metabolism of most IV anesthetic agents [1,22,23].
●Diminished albumin levels, resulting in larger free-drug concentrations of highly protein-bound drugs (eg, propofol) [1].
Kidney function — Aging causes variable declines in glomerular filtration rate, creatinine clearance, and renal functional reserve that may be underestimated by the serum blood urea nitrogen and creatinine alone [24,25]. Common comorbidities in older adults (eg, diabetes, hypertension, and vascular disease) can cause further decline in renal function. Implications of these changes include:
●Increased plasma concentration of renally excreted IV agents [1,22,23,26].
●Decreased ability to maximally dilute urine with decreased ability to handle a salt or water load.
●Increased susceptibility to nephrotoxic effects of IV contrast or medications such as nonsteroidal anti-inflammatory drugs (NSAIDs).
Pharmacokinetic changes — Decreased total body water (by 10 to 15 percent) and muscle mass result in a lower central compartment volume and higher initial plasma drug concentrations (ie, effective concentration) for many anesthetic agents (eg, an induction dose of propofol) [3,6,22]. Increased body fat (by 20 to 40 percent) also results in a larger volume of distribution for lipid-soluble agents, with slow release from this relatively large adipose reservoir that prolongs the clinical drug effect [1,3,6,22,23]. Finally, elimination half-life may be longer and clearance may be decreased due to renal and hepatic changes (see 'Liver function' above and 'Kidney function' above). This leads to greater drug effects after repeated or continuous dosing of anesthetic agents [1,3,6,22,23,27,28]. (See 'Selection and dosing of anesthetic agents' below and "Drug prescribing for older adults" and "Normal aging".)
Immunological changes — Chronic systemic inflammation and immunosenescence are associated with the development of many age-related chronic illnesses, including anemia and frailty, contributing to exacerbated inflammatory responses to surgical stress and adverse outcomes [29,30].
PREANESTHESIA CONSULTATION —
Older age is a risk factor for perioperative mortality and morbidity. However, the impact of absolute age on perioperative outcomes is modest and should not be used as a sole criterion to guide decisions regarding patient selection for a surgical procedure or preoperative testing [6,31]. (See 'Mortality and morbidity' below and "Preoperative evaluation for noncardiac surgery in adults", section on 'Older age'.)
Preanesthesia evaluation includes a review of the medical history and an anesthesia-directed physical examination. An example of a checklist to ensure assessment of age-related issues is shown in the table (table 1). Particular attention is paid to the management of chronic illnesses, anemia, frailty, and baseline cognitive function, as discussed below and in separate topics. (See "Preoperative evaluation for noncardiac surgery in adults", section on 'Assessment for aging related conditions that increase risk' and "Overview of preoperative evaluation and management for cardiac surgery in adults", section on 'Noncardiac risk factors'.)
Assessment for anemia — Anemia due to iron deficiency, chronic disease/inflammation, malnutrition, or bone marrow malfunction is common in older adults [6]. (See "Diagnostic approach to anemia in adults", section on 'Older adults'.)
A large retrospective study included 8643 adults >65 years who had preoperative hemoglobin value measurements, frailty screening (with the Fried Frailty Tool (see "Frailty", section on 'Instruments developed to identify frailty')), and cognitive screening (eg, time required to draw a clock (see "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Preoperative cognitive screening')) [32]. Preoperative mild anemia (with hemoglobin <12 but >11 g/dL), moderate anemia (with hemoglobin <11 but >8 g/dL), and severe anemia (with hemoglobin <8 g/dL) were diagnosed in 16.8 percent, 9.5 percent, and 0.4 percent of these patients, respectively. Lower preoperative hemoglobin levels were associated with longer clock drawing times indicating preoperative cognitive dysfunction and higher Fried Frailty scores indicating frailty. Furthermore, risk of death within one year of surgery was higher in older adults with moderate/severe anemia (odds ratio [OR] 3.6, 95% CI 2.7-4.9), or even mild anemia (OR 2.7, 95% CI 2.1-3.5), compared with those who were not anemic [32].
Timely management of preoperative anemia is necessary, as discussed in the algorithm and in a separate topic (algorithm 1). (See "Perioperative blood management: Strategies to minimize transfusions", section on 'Treatment of anemia and iron deficiency'.)
Assessment for frailty — Frailty in older patients is defined as an aging-related syndrome of physiologic decline and reduced tolerance to medical and surgical interventions (see "Frailty", section on 'Concepts and definitions'). Frail older patients often present for surgery with an increased burden of symptoms including weakness and fatigue, medical complexity, and an accelerated decrease in functional physiologic reserve that may exceed that expected from advanced age alone [33]. Evaluation and general management of frailty are discussed in detail in a separate topic. (See "Frailty".)
●Identification of frailty – Identification of frailty in the preoperative period can be helpful to inform patient and family discussions regarding surgical techniques, postoperative recovery strategies, and likely outcomes [6,33-39]. Estimates of the prevalence of frailty in older patients (mean age 70 years) undergoing nononcologic surgery are approximately 30 percent and may be as high as 50 percent in older patients who require cancer surgery [36,40]. Age-related frailty is particularly common in critically ill surgical patients [41,42].
Both accuracy and feasibility of the selected assessment tools are important to successfully implement routine preoperative screening for frailty [35,43]. Several standardized multidimensional tools have been used to assess preoperative frailty [35,43-55]. These include phenotypic scales, employing different physical and clinical characteristics or the deficit accumulation models that characterize frailty severity based on documentation of accumulation of deficits identified. These instruments are discussed in a separate topic. (See "Frailty", section on 'Instruments developed to identify frailty'.)
However, despite the availability of multiple assessment tools, preoperative frailty screening is not routinely performed in many centers due to a lack of agreement on the optimal tool, as well as difficulty implementing additional assessments into busy clinical practices.
●Effects on outcomes – Frailty predicts postoperative mortality and morbidity including delirium or cognitive impairment, as well as longer hospital stay, discharge to a skilled nursing facility, and long-term functional decline [33,35,44-47,55-63].
A 2023 systematic review of databases that included 18 studies with 4479 patients noted that mortality was higher for frail patients compared with nonfrail patients at 30 days (odds ratio [OR] 6.62, 95% CI 2.80-15.61) and six months (OR 3.11, 95% CI 2.06-4.68) [63]. Also, frailty was associated with postoperative complications (OR 3.11, 95% CI 2.06-4.68) and postoperative delirium (OR 2.65, 95% CI 1.85-3.80). A 2022 study in 992 older adults (mean age 79.2 ± 7.1 years) reported mortality at one year after major surgery, noting that it was fourfold higher in frail patients (27.8 percent, 95% CI 21.2-34.3 percent) compared with nonfrail patients (6.0 percent, 95% CI 2.6-9.4 percent) [34].
Costs are also affected. In a study of 171,576 elective surgical patients who were ≥66 years, 13.5 percent were identified to have preoperative frailty [64]. Costs for frail patients were 1.5fold greater than for nonfrail older adults.
●Role of prehabilitation – It has been suggested but not yet proven that surgical outcomes may be improved in some older frail patients by optimizing preoperative condition and improving physiologic reserve with a prehabilitation program [6,36,37,65-74]. This may include smoking cessation, as well as exercise training, nutritional supplementation, and a multidisciplinary approach to postoperative care and discharge planning that includes a geriatrician. Details are available in a separate topic. (See "Overview of prehabilitation for surgical patients".)
Assessment of baseline cognitive function — Many centers perform routine preoperative screening for cognitive impairment, as well as for frailty, in all older adults (≥60 or 65 years of age) [6,75,76]. The American Society of Anesthesiologists (ASA) Brain Health Initiative guidelines suggest that baseline cognition should be evaluated in patients older than 65 years, particularly those with risk factors for preexisting cognitive impairment [77]. Older patients should be informed of the possibility of postoperative exacerbation of a preexisting cognitive impairment (eg, confusion, inattention, memory problems), although these effects of anesthesia and surgery are usually temporary [6,61,77]. Planned preventive strategies are also discussed. Details regarding perioperative neurocognitive disorders are found in a separate topic. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies".)
Role of palliative care — In some cases, such discussions include a decision regarding whether or not the surgical procedure is appropriate due to adverse impact on quality of life, and/or consideration of a palliative care consultation [6,36,38,78]. In selected high-risk surgical patients, a palliative care consultation may improve end-of-life experiences for the individual and their family [79]. The aim of these consultations is to communicate goals of care for a potentially difficult or prolonged recovery and to provide symptomatic and psychosocial support in the postoperative period. (See "Benefits, services, and models of subspecialty palliative care".)
Challenges for the nursing home patient — Preoperative assessment of nursing home patients presents a particular challenge for the anesthesiologist. These patients usually have extensive medical comorbidities and frailty (see 'Assessment for frailty' above). Furthermore, dementia is estimated to be present in one-half to two-thirds of nursing home residents. Patients with dementia have higher perioperative mortality after major surgery (32.7 percent, 95% CI 24.3-41.0 percent) compared with those without dementia (11.6 percent, 95% CI 8.8-14.4 percent) [34]. (See "Risk factors for cognitive decline and dementia", section on 'Age'.)
An additional visit to the hospital for preoperative consultation and testing may be impractical and "low yield" in patients with significant physical disabilities or dementia. Often, a member of the anesthesia team will preview the patient's medical conditions and most recent laboratory tests to determine if further testing is likely to be useful. If not, the final preoperative assessment is completed on the day of surgery at the hospital or ambulatory surgery center. In such cases, it is particularly important to communicate to the outside facility regarding instructions regarding the need to administer or withhold each chronically administered medication and to explain the timing for ensuring nothing by mouth (nil per os [NPO]) status. Furthermore, for patients who are incompetent and unable to provide consent (eg, due to dementia), arrangements are made to obtain telephone consent from a family member or guardian [80].
Management of current medications — Obtaining an accurate medication history, including both prescription and over-the-counter medications, may require extra effort since older adult patients often forget or confuse their medication regimen [81,82]. The incidence of adverse drug-related events is high in older patients taking multiple medications (polypharmacy) [83-85]. Thus, the opportunity for reconciliation of the medication schedule is one distinct benefit of a scheduled patient visit to the preoperative clinic [86].
Examples of medications commonly used by older patients that are potentially relevant for anesthetic care include the following (see "Perioperative medication management"), which are discussed in detail in separate topics:
●Antiplatelet agents or oral anticoagulants must be managed if a neuraxial anesthetic is planned. (See "Neuraxial anesthesia/analgesia techniques in the patient receiving anticoagulant or antiplatelet medication".)
●Angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) administered within 12 hours of anesthetic induction are associated with an increased risk of intraoperative hypotension. In many centers, ACE inhibitors and ARBs are held for a period of 24 hours prior to surgery or are administered the evening dose before surgery (and not on the morning of surgery), as discussed separately. (See "Anesthesia for patients with hypertension", section on 'Antihypertensive medication management'.)
PREOPERATIVE TESTING —
Routine preoperative testing is not recommended before minor procedures in older adults. In a prospective randomized trial that included more than 18,000 older patients having cataract surgery, no differences in complications were noted in those who received routine preoperative testing (complete blood count, and measurement of serum levels of electrolytes, urea nitrogen, creatinine, and glucose) compared with those who received tests only if indicated by medical condition(s) [87].
Notably, the following caveats apply to older adults:
●Electrocardiogram – An electrocardiogram (ECG) for patients with coronary heart disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or other significant structural heart disease and known cardiovascular risk factors undergoing intermediate or high cardiac risk surgery is reasonable (table 2 and table 3) [88]. (See "Evaluation of cardiac risk prior to noncardiac surgery".)
Age alone is not an indication for ECG [89], although some institutions had historical guidelines recommending a preoperative ECG in adult patients older than 55 years. These guidelines were based on the observation that older patients have a high incidence of preoperative changes on the ECG [90-92], despite data showing little predictive value of the preoperative ECG [93,94]. In a prospective observational study of 513 older adult patients undergoing noncardiac surgery, 75 percent had at least one abnormality on the baseline ECG [92]. However, these abnormalities were not associated with increased risk for cardiac events.
●Chest radiograph – In general, a preoperative chest radiograph (CXR) is unnecessary for older patients undergoing elective non-thoracic surgery [89]. In patients with symptomatic cardiac or pulmonary disease, a CXR may be obtained before a high-risk surgical procedure, if not performed within the past six months. (See "Evaluation of perioperative pulmonary risk".)
●Laboratory tests – There is no consensus on the specifics of routine testing in older patients.
•Hemoglobin and hematocrit are not routinely recommended [89], but are typically obtained before major surgical procedures with significant expected blood loss (eg, procedures with >10 percent chance of needing a transfusion or >500 mL blood loss), and in individuals likely to have preoperative anemia due to a known underlying condition. Depending on the cause and degree of anemia, the urgency of the procedure, and the expected amount of blood loss and other risk factors, surgery may be postponed to diagnose the cause and correct anemia when feasible (algorithm 1). (See "Perioperative blood management: Strategies to minimize transfusions", section on 'Treatment of anemia and iron deficiency' and "Perioperative blood management: Strategies to minimize transfusions", section on 'Selective laboratory testing'.)
•Preoperative creatinine and albumin may be measured before moderate- or high-risk surgery in frail older patients or those with a known history of liver disease or chronic illness since these patients have a relatively high incidence of renal dysfunction and malnutrition [95]. (See "Preoperative evaluation for noncardiac surgery in adults", section on 'Older age'.)
●Other screening tests – Other screening tests (eg, echocardiography, pulmonary function testing) are ordered according to criteria used for adult patients of any age since there are no data demonstrating that routine use of such testing is useful to predict or manage postoperative complications in older adults [96]. (See "Evaluation of cardiac risk prior to noncardiac surgery", section on 'Testing to further define risk' and "Evaluation of perioperative pulmonary risk", section on 'Preoperative risk assessment'.)
PREMEDICATION —
We avoid or minimize the use of benzodiazepine premedication in older adults because of the increased risk for postoperative delirium, particularly in patients with a history of delirium, frailty, or cognitive impairment [97-99]. However, despite guidelines recommending avoidance of benzodiazepine administration to older patients [98], many do receive a short-acting agent such as midazolam to alleviate anxiety [97,100]. Further discussion regarding benzodiazepines and other agents (eg, gabapentinoids, opioids, ketamine) as risk factors for delirium and other perioperative neurocognitive disorders is available in a separate topic. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Intravenous agents associated with higher risk'.)
Acetaminophen and an oral cyclooxygenase 2 (COX-2) inhibitor such as celecoxib (if there are no contraindications) are often administered in the preoperative period as part of a multimodal analgesic regimen, particularly for patients participating in enhanced recovery after surgery (ERAS) protocols. Details are discussed separately. (See "Overview of enhanced recovery after major noncardiac surgery (ERAS)", section on 'Preoperative medications'.)
CHOICE OF ANESTHETIC TECHNIQUES —
The choice of anesthetic technique for the older patient should be guided by the requirements of the surgical procedure, coexisting disease(s), the need to prevent postoperative complications, and patient preferences.
Neuraxial versus general anesthesia — Selection of neuraxial or another regional anesthetic versus general anesthesia should be guided primarily by the requirements of the surgical procedure, coexisting disease(s), the need to prevent postoperative complications, and patient preferences [101,102].
For example, general anesthesia may be preferable in the following clinical scenarios (see "Anesthesia for orthopedic trauma", section on 'Choice of anesthetic technique'):
●Patients receiving anticoagulant or antiplatelet medication or with coagulopathy due to other reasons, such that neuraxial anesthesia and deep peripheral nerve blocks are relatively contraindicated. (See "Neuraxial anesthesia/analgesia techniques in the patient receiving anticoagulant or antiplatelet medication" and "Lower extremity nerve blocks: Techniques", section on 'Side effects and complications'.)
●Patients with decreased cardiac preload (eg, due to hypovolemia or expected major blood loss) that would be exacerbated by sympathetic blockade with resultant severe hypotension.
●Requirement for deep sedation due to patient inability to lie comfortably in the position necessary for surgery.
●Anxiety, reluctance to be awake, or inability to cooperate or communicate (eg, due to dementia).
●Anticipated prolonged duration of a surgical procedure.
When either neuraxial or general anesthesia could be used for a surgical procedure in older adults, randomized trials have not found differences in outcomes after general compared with neuraxial analgesia. In a 2021 randomized trial of 1600 patients ≥50 years old (mean age 77.7 ± 10.7) undergoing hip fracture surgery under general or spinal anesthesia, mortality and recovery of ambulation at 60 days were similar [103]. In a follow-up study of these patients published in 2024, long-term outcomes over the first year after surgery including mortality and recovery of independence in ambulation remained similar in patients who had general versus spinal anesthesia [104]. One randomized trial with 154 patients noted that hypotension is less frequent during hip fracture surgery (odds ratio [OR] 5.6, 95% CI 2.7-11.7) [105].
Some observational studies have noted that neuraxial or other regional anesthetic techniques may reduce pulmonary complications and the need for postoperative mechanical ventilation compared with general anesthesia [106,107], particularly in older patients with chronic obstructive pulmonary disease (COPD) [108,109] (see "Anesthesia for patients with chronic obstructive pulmonary disease", section on 'Choice of anesthetic technique'). Other observational studies have noted that costs or hospital length of stay (LOS) may be influenced by anesthetic choice. In one study with >800,000 patients undergoing total knee replacements and >370,000 patients undergoing total hip replacements, lower hospital costs were found in centers frequently employing a neuraxial technique for these procedures compared with those where a neuraxial technique was used less often [110]. A 2016 meta-analysis of 29 studies involving 10,488 patients noted that neuraxial anesthesia significantly reduced length of stay (weighted mean difference −0.40 days, 95% CI −0.76 to −0.03 days) compared with general anesthesia [111]. Other retrospective studies have noted that discharge to a post-acute care facility following total hip or knee replacement, rather than discharge home, may be more common when general anesthesia rather than a neuraxial technique is employed [112,113].
Monitored anesthesia care with sedation — A monitored anesthesia care technique is often selected for older adults who require a diagnostic or therapeutic procedure, especially in remote locations such as endoscopic gastrointestinal or interventional radiology suites [114-116]. (See "Anesthesia for gastrointestinal endoscopy in adults", section on 'Choice of anesthetic technique' and "Considerations for non-operating room anesthesia (NORA)", section on 'Selection of anesthetic technique'.)
During monitored anesthesia care, short-acting agents are administered to provide analgesia, sedation, and anxiolysis as necessary; however, excessive anesthetic depth is avoided, and rapid recovery is desired. Notably, progression from a "light" level of sedation to "deep" sedation (or unconsciousness) is not uncommon and may occur rather suddenly [3]. Since older patients are particularly susceptible to developing airway obstruction, hypoxemia, hypercapnia, or aspiration (due to reduced pharyngeal sensitivity), doses of all administered sedative and analgesic medications are reduced [3,117]. Also, supplemental oxygen is typically administered to reduce the risk of hypoxemia because older patients have a lower baseline arterial oxygen tension (PaO2) [118]. Continuous vigilant monitoring is necessary, including constant communication and monitoring of respiratory rate [3]. Routine use of end-tidal carbon dioxide (ETCO2) level monitoring is recommended in spontaneously breathing older patients since significant hypercapnia may develop even when oxygen saturation levels remain normal [3,119]. (See 'Selection and dosing of anesthetic agents' below.)
Similar to considerations for neuraxial or regional anesthesia, general anesthesia may be preferred in some older adults if deep sedation is likely to be necessary, in patients with anxiety, reluctance to be awake, or inability to cooperate or communicate, or if the procedure is prolonged in duration. (See 'Neuraxial versus general anesthesia' above.)
Details regarding management of patients undergoing surgical or other invasive procedures during monitored anesthetic care are available in a separate topic. (See "Monitored anesthesia care in adults".)
INTRAOPERATIVE MANAGEMENT
Positioning — Older patients are often more susceptible to nerve and other pressure point injury due to poor peripheral circulation and friable skin [120]. Details are discussed in a separate topic. (See "Patient positioning for surgery and anesthesia in adults".)
Selection and dosing of anesthetic agents
General considerations — Older adult patients are more sensitive to drugs due to age-related changes in pharmacokinetics and pharmacodynamics [1,3,6,22,23]. Since drug sensitivity is increased and drug clearance is decreased in older adults, there is an enhanced response to a given drug dose. Avoiding excessive anesthetic depth which may lead to hypotension or blood pressures significantly lower than baseline values is particularly important in older adults [77]. Thus, anesthetic dosing should be age-adjusted [1]. (See 'Impact of age-related physiologic changes on anesthetic care' above.)
Strategies to avoid excessive anesthetic depth and other side effects of anesthetic agents (eg, hypotension) include:
●Reducing doses of induction agents. Doses of anesthetics and adjuvant agents are also reduced during the maintenance phase of anesthesia, particularly if several anesthetic agents are coadministered. (See "Maintenance of general anesthesia", section on 'Intravenous anesthetic agents and techniques'.)
●Increasing the interval between repeat doses.
●Using shorter-acting agents.
●Brain function monitoring. Although processed electroencephalography (EEG) is often employed, lower anesthetic concentrations produce burst suppression in older adults, and potentially erroneous burst suppression episodes are more common in older patients [121]. Nevertheless, guidelines from the American Society of Anesthesiologists (ASA) Brain Health Initiative note the importance of avoiding high doses of anesthetic agents to maintain low brain function monitor values, as this may lead to excessive anesthetic depth [77]. These concepts and supporting data are discussed separately. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Avoid excessive depth during general anesthesia'.)
Intravenous anesthetic and adjuvant agents — Specific considerations for individual anesthetic agents include the following:
●Propofol – Older adult patients have an altered pharmacodynamic response to propofol. As judged by the EEG, older subjects are approximately 30 percent more sensitive to its effects [122]. In addition, clearance of propofol is decreased [22].
For these reasons, the initial induction dose of propofol and subsequent bolus doses should be reduced by 40 to 50 percent to 1 mg/kg to 1.75 mg/kg and should be slowly administered [1,22,123,124] (see "General anesthesia: Intravenous induction agents", section on 'Propofol'). Similarly, maintenance doses during an ongoing infusion of propofol must be decreased by 30 to 50 percent, in order to avoid a doubling of recovery time [22]. (See "General anesthesia: Intravenous induction agents", section on 'Dosing'.)
●Etomidate – Etomidate is often the preferred anesthetic induction agent for older patients with known cardiovascular compromise or hemodynamic instability since it has minimal hemodynamic side effects [14]. Notably, the plasma concentration of etomidate at any given dose is higher in the older patient because of a decreased volume of distribution and diminished clearance. Thus, although the standard induction dose of etomidate is 0.3 mg/kg, this dose is often reduced to 0.2 mg/kg. (See "General anesthesia: Intravenous induction agents", section on 'Etomidate'.)
●Ketamine – Ketamine is not used often in older patients because of its unique cardiovascular effects (increases in blood pressure and heart rate due to a centrally-mediated sympathetic response), as well as the undesirable side effect of postoperative delirium [14,125]. However, ketamine may be selected for patients with hemodynamic compromise caused by hypovolemia or cardiomyopathy in the absence of coronary artery disease. Also, since ketamine is a bronchial smooth muscle relaxant, it may be useful in older patients with reactive airway disease. (See "General anesthesia: Intravenous induction agents", section on 'Ketamine'.)
●Opioids – All opioids are approximately twice as potent in older patients. Also, since opioids have the potential to cause respiratory depression, the increased brain sensitivity and decreased clearance of opioids in older patients can result in severe hypoventilation or apnea [126]. (See "Perioperative uses of intravenous opioids in adults: General considerations", section on 'Dosing considerations'.)
•Short-acting opioids – For fentanyl, sufentanil, and alfentanil, respiratory depression is primarily a pharmacodynamic effect due to age-related increased brain sensitivity to opioids [22].
For remifentanil, there are also changes in pharmacokinetics due to decreased volume of the central compartment and decreased clearance, so that only half of the bolus dose is required.
•Long-acting opioids – For morphine, the volume of distribution is increased in older adults, and renal clearance is reduced for the parent drug, as well as its active metabolite, morphine-6-glucuronide [26,127]. Thus, there is an enhanced analgesic effect and prolonged duration of action after each dose of morphine. Clearance is further reduced in patients with renal insufficiency.
For hydromorphone, initial doses are reduced by 25 to 50 percent to avoid a prolonged duration since hydromorphone has primary renal clearance [26]. (See 'Kidney function' above.)
●Medications to avoid or use with caution – Several medications are minimized or avoided in older adults [6]:
•Benzodiazepines – As noted above, benzodiazepines are avoided if possible, or at least these agents are minimized. (See 'Premedication' above.)
If necessary to alleviate anxiety (eg, during monitored anesthetic care (see "Monitored anesthesia care in adults", section on 'Midazolam')), an initial intravenous (IV) dose of midazolam is usually only 0.25 to 1 mg, and the interval between additional doses may be longer than in younger patients. Both pharmacodynamic changes (ie, increased brain sensitivity) and pharmacokinetic changes (ie, decreased clearance due to decreased hepatic perfusion and increased volume of distribution due to increased body fat) occur in older adults, necessitating reduction of midazolam doses [1,22,122,128] (see 'Impact of age-related physiologic changes on anesthetic care' above). Cautious dosing is particularly necessary when an opioid or other anesthetic agent is concurrently administered since respiratory depression is a dose-related side effect of each drug, and effects can be synergistic. Furthermore, midazolam occasionally causes paradoxical worsening of agitation in older patients. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Intravenous agents associated with higher risk'.)
Although limited data are available, use of an infusion of the ultra-short-acting benzodiazepine, remimazolam may be another option. Details are discussed separately. (See "Monitored anesthesia care in adults", section on 'Remimazolam'.)
•Other agents – Meperidine, anticholinergics (particularly scopolamine), diphenhydramine, and metoclopramide since these agents increase risk for postoperative delirium and other forms of perioperative neurocognitive disorder [6]. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Intravenous agents associated with higher risk'.)
Antipsychotic agents such as haloperidol are avoided in older patients who have dementia with Lewy bodies because of the possibility of severe reactions (eg, impaired consciousness, autonomic dysfunction, neuroleptic malignant syndrome, irreversible parkinsonism). (See "Clinical features and diagnosis of dementia with Lewy bodies", section on 'Antipsychotic sensitivity' and "Prognosis and treatment of dementia with Lewy bodies", section on 'Antipsychotic drugs'.)
Inhalation anesthetic agents — The minimum alveolar concentration (MAC) at 1 atmosphere preventing movement in 50 percent of patients exposed to a surgical incision of all inhalation agents decreases by approximately 6 percent per decade after age 40 years (figure 2 and figure 3 and figure 4). By age 90 years, MAC is reduced by 30 percent [5,129,130]. Similarly, the anesthetic requirement to produce unconsciousness (ie, absence of response to commands [MACawake] is decreased with age). Although reasons for age-related decline in MAC and MACawake are not fully understood, likely mechanisms include a combination of age-related effects on synaptic activity and neurotransmitter function in the brain, cerebral atrophy, and changes in cerebral circulation [129,130]. (See "Inhalation anesthetic agents: Clinical effects and uses", section on 'Influence of patient-related factors'.)
An age-adjusted end-tidal anesthetic concentration (ETAC) is initially targeted, with the goal of maintaining adequate anesthesia while avoiding excessive anesthetic depth (figure 2 and figure 3 and figure 4) [77]. Subsequently, anesthetic concentration is continuously monitored and titrated according to the individual patient's responses. Neuromonitors such as the EEG may be useful to guide titration of a volatile agent and maintain optimal anesthetic depth [77]. Notably, no individual volatile anesthetic agent has been associated with an increased risk of developing postoperative neurocognitive disorder in older adults. (See "Accidental awareness during general anesthesia", section on 'End-tidal anesthetic concentration' and "Accidental awareness during general anesthesia", section on 'Brain monitoring' and "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Inhalation anesthetic agents'.)
Neuromuscular blocking agents — Various neuromuscular blocking agents (NMBAs), including succinylcholine, may have a prolonged onset time as well as a prolonged duration in older patients. Likely mechanisms include decreased muscle blood flow and decreased cardiac output [131].
In general, we select shorter-acting NMBAs and use these sparingly when possible because age-related reductions in hepatic metabolism and renal excretion may result in prolonged duration of action for certain agents (eg, rocuronium) [6,131]. Recovery of muscle function after administration of sugammadex, which facilitates rapid reversal from neuromuscular blockade induced by rocuronium, is slightly slower in older patients [132].
Age has little effect on NMBAs eliminated by other means, such as ester hydrolysis and Hoffmann degradation (eg, atracurium, mivacurium, and cisatracurium). Nevertheless, a peripheral nerve stimulator should be used to guide dosing of all NMBAs. It is particularly important to ensure reversal of neuromuscular blockade if extubation is planned at the end of the surgical procedure. Even a small amount of residual neuromuscular blockade can impair pharyngeal function in older patients, predisposing them to the development of aspiration pneumonia [3,133]. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Consequences of residual block' and "Postoperative airway and pulmonary complications in adults: Etiologies and initial assessment and stabilization", section on 'Acute upper airway obstruction'.)
Furthermore, older patients with Alzheimer disease and other forms of dementia may be taking cholinesterase inhibitors (eg, donepezil, rivastigmine, galantamine). Chronic administration of these medications may lead to reduced plasma cholinesterase, thereby prolonging the duration of succinylcholine [80]. Cholinesterase inhibitors may also interfere with the action of anticholinesterase agents such as neostigmine, with unpredictable responses to these agents.
Hemodynamic management — As noted above, changes in the older adult's cardiovascular system such as vascular stiffening and autonomic changes may lead to hemodynamic instability during anesthesia and surgery [13] (see 'Cardiovascular system' above). Prevention and management of perioperative hemodynamic aberrations are discussed separately. (See "Hemodynamic management during anesthesia in adults".)
Periods of intraoperative hypotension may contribute to adverse cardiac events in older patients [134,135]. Some require an intraoperative mean arterial pressure target higher than the typically targeted 65 mmHg, particularly those with chronic hypertension [136,137]. (See "Anesthesia for patients with hypertension", section on 'Determination of target blood pressure values'.)
Avoidance of hypothermia — Perioperative hypothermia is more frequent, pronounced, and prolonged in older adults, who have compromised ability to quickly regain thermoregulatory control [138]. Prevention and management of hypothermia (or hyperthermia) during the perioperative period are discussed in a separate topic. (See "Perioperative temperature management".)
POSTOPERATIVE PAIN MANAGEMENT
General considerations — Although there is an age-related decrease in pain perception, postoperative analgesia is a critical aspect of perioperative anesthetic care for the older patient [139-141]. Multimodal combinations of opioids, nonopioid agents (eg, acetaminophen, nonsteroidal anti-inflammatory agents [NSAIDs], dexmedetomidine, or steroids such as dexamethasone or methylprednisolone) may be used, as well as neuraxial and regional analgesic techniques. Management begins with careful assessment of postoperative pain, which may be challenging in older patients with some degree of chronic pain, or extremely difficult in those with mental status changes [142]. Although numerical verbal pain scales are superior to nonverbal methods of assessment, cognitively impaired patients may not understand these scales [143]. Patients with advanced dementia and those who are nonverbal may respond best to visual analog scales that use faces expressing pain and sadness.
Selection of analgesic agents and techniques
●Opioids – Although opioids may precipitate or worsen delirium, inadequate pain relief is also associated with a greater likelihood of delirium and subsequent morbidity in older patients [144,145]. To reduce the risk of delirium and other opioid-related side effects, we employ a multimodal approach to pain management [26,146,147]. (See "Hospital management of older adults" and "Approach to the management of acute pain in adults".)
If systemic opioids are necessary for pain control in the immediate postoperative period, doses are reduced [22,26,127,142,143,146] (see "Perioperative uses of intravenous opioids in adults: General considerations", section on 'Dosing considerations' and 'Impact of age-related physiologic changes on anesthetic care' above). Notably, initial titration of opioids to successfully control pain in older patients requires extra time and may necessitate a longer stay in the post-anesthesia care unit [148,149]. If additional intravenous (IV) opioid doses are needed after initial titration, patient-controlled anesthesia (PCA) should be implemented [150]. If delirium or other factors preclude use of PCA, regularly scheduled age-adjusted opioid dosing is an option. Subcutaneous administration may be employed when no reasonable alternatives exist, but absorption may be erratic or inadequate in older adults with edema or regional hypoperfusion.
●Nonopioid analgesics – Nonopioid analgesics are commonly used in the postoperative period [147]:
•Acetaminophen – For mild postoperative pain, acetaminophen 650 to 1000 mg administered every six hours is the nonopioid of choice, unless contraindicated due to hepatic disease. The addition of scheduled acetaminophen to a morphine PCA results in improved pain scores and lower overall opioid doses in some patients [147,151]. IV acetaminophen may be used in patients in whom oral or rectal administration is not an option. (See "Nonopioid pharmacotherapy for acute pain in adults", section on 'Acetaminophen'.)
•Nonsteroidal anti-inflammatory drugs (NSAIDs) – NSAIDs such as intravenous ketorolac or oral ibuprofen are often administered in combination with acetaminophen after orthopedic surgery in older adults [140,147,150]. However, NSAIDs carry a significant risk of transient platelet dysfunction and bleeding, as well as gastrointestinal hemorrhage and renal insufficiency. (See "Nonselective NSAIDs: Overview of adverse effects".)
Furthermore, even short-term use of NSAIDs may increase risk for adverse cardiovascular events including myocardial infarction and stroke, and these agents can modestly exacerbate heart failure. (See "NSAIDs: Adverse cardiovascular effects".)
For these reasons, the dose of ketorolac should be reduced to 15 mg every six hours in older patients, with no more than 60 mg administered in a 24-hour period [152]. Also, higher doses and longer durations or chronic use of oral NSAIDs are typically avoided in older adults [147].
•Other nonopioid analgesics – Dexmedetomidine and steroids such as dexamethasone or methylprednisolone are occasionally used as part of a multimodal opioid-sparing pain management strategy in older adults [147]. These agents, as well as acetaminophen and NSAIDs, may decrease risk of postoperative neurocognitive disorders.
Details regarding use of nonopioid agents are discussed in other topics. (See "Approach to the management of acute pain in adults", section on 'Nonopioid analgesics and adjuncts' and "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Intravenous agents associated with lower risk'.)
●Neuraxial and regional analgesia – For selected patients, continuous epidural analgesia is appropriate as the planned primary method for controlling pain [125,153,154] (see 'Neuraxial versus general anesthesia' above). Peripheral nerve blocks and adjuvant techniques such as local anesthetic infiltration are also commonly used to reduce the need for systemic opioids. (See "Overview of peripheral nerve blocks", section on 'Indications'.)
OUTCOMES
Mortality and morbidity — Although older age is one risk factor for perioperative mortality and morbidity, preoperative comorbidities, overall physical condition (ie, frailty and functional reserve), and risk factors for delirium are more important predictors, as noted above. (See 'Assessment for frailty' above and 'Assessment of baseline cognitive function' above.)
●Mortality – Older age is a risk factor for perioperative mortality, but preoperative comorbidities, frailty, and functional reserve are other important predictors of mortality in this age group, as noted above [58,89,134,155-159]. The following studies illustrate the mortality rate in older adults in the United States:
•A 2024 retrospective cohort study that included 3,552,9065 Medicare patients ≥65 years old who had a surgical procedure, 0.6 percent (22,103) died within 30 days [160].
•A 2023 prospective single-center study that included 2,176 patients >70 years, 12 percent had died within six months, while 23 percent had significant disability [161].
•In a 2005 study of the Veterans Affairs National Survey Quality Improvement Project (NSQIP) database of inpatient noncardiac surgery, 26,368 patients ≥80 years old suffered a significantly higher mortality at 30 days compared with 568,263 patients <80 years old (8 versus 3 percent) [155]. Although mortality varied widely depending on the type of surgery, the overall adjusted odds ratio (OR) for each additional year of age was 1.05 (ie, a 5 percent increase in mortality risk for every year of age over 80).
Exacerbating risk factors for perioperative mortality in older patients include:
•Urgent or emergency surgery – Nonelective surgery is associated with higher mortality in older adults, as noted in a study of 1193 major surgeries (from 992 community-living participants), (22.3 percent, 95% CI 17.4-27.1 percent) compared with elective surgery (7.4 percent, 95% CI 4.9-9.9 percent) [34]. Older studies have noted similar findings [134,155,156,158,162,163]. For those with hip fracture, an associated risk factor is the wait time for emergency repair; expeditious surgery has been associated with better patient outcomes [135,164]. (See "Hip fracture in older adults: Epidemiology and medical management", section on 'Timing of surgical intervention'.)
•Invasiveness of the surgical procedure [155-158,165-168].
•High American Society of Anesthesiologists (ASA) risk score (table 4) [155-158].
•Preexisting diagnosis of heart failure [134,162,166,167]. In a study of older patients undergoing noncardiac surgery, death occurred in 9 percent of patients with ischemic or nonischemic heart failure, which was significantly higher than patients with coronary artery disease (3 percent) [167]. Risk is higher in older heart failure patients after both major surgery and minor outpatient procedures (ie, colonoscopy, cataract surgery, or cystoscopy) [166,167].
Mortality specifically related to anesthesia has been studied in approximately 106 million patients undergoing surgery during the years 1999 to 2005 [169]. Anesthetic issues causing death are rare, occurring in eight per million surgical patients. However, patients ≥85 years old suffer the highest death rate (approximately 20 per million) [169].
●Cardiac complications – Advanced age has not been definitively proven to independently increase perioperative risk for postoperative cardiac death or major cardiac complications, including nonfatal myocardial infarction and heart failure. Age is noted as a minor risk factor in the 2014 American College of Cardiology/American Heart Association (ACC/AHA) perioperative guidelines since perioperative myocardial infarction confers a higher mortality in older adults [88]. (See "Evaluation of cardiac risk prior to noncardiac surgery" and "Perioperative management of heart failure in patients undergoing noncardiac surgery", section on 'Severity of heart failure syndrome'.)
●Pulmonary complications – Even healthy older patients have a substantial risk of pulmonary complications after surgery [21] (see "Evaluation of perioperative pulmonary risk"). The most important complications are atelectasis, pneumonia, respiratory failure, and exacerbation of underlying chronic lung disease.
In a 2006 systematic review, patients aged 50 to 59 years, 60 to 69 years, 70 to 79 years, and ≥80 years had odds ratios of 1.50 (95% CI 1.31-1.71), 2.28 (95% CI 1.86-2.80), 3.90 (95% CI 2.70-5.65), and 5.63 (95% CI 4.63-6.85), respectively, compared with patients <50 years old [21].
Significant risk factors for pulmonary complications include preexisting chronic obstructive pulmonary disease, chronic heart failure, and invasive surgical procedures (eg, abdominal surgery, aortic aneurysm repair, and non-respective thoracic surgery) [21]. Risk may be mitigated by cessation of smoking for more than three months before surgery in those who use tobacco [170] (see "Smoking or vaping: Perioperative management"). Also risk of respiratory failure is exacerbated if reversal of neuromuscular blocking agents (NMBAs) is inadequate, particularly in frail patients more susceptible to fatigue [133]. (See 'Neuromuscular blocking agents' above.)
●Acute kidney injury – Risk for the development of acute kidney injury, defined as an increase in serum creatinine of at least 2 mg/dL or acute renal failure requiring dialysis, is increased in older patients [171].
●Delirium – Advanced age is a risk factor for perioperative neurocognitive disorder (NCD) [172-177]. In particular, postoperative delirium is common in older adults undergoing major surgery (ranging from 4 to 55 percent), with the highest incidence occurring after emergency, cardiac, or major orthopedic surgery [99,174,178-187]. Notably, up to 40 percent of older adults who develop postoperative delirium never return to their preoperative cognitive baseline [174,188]. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Prognosis'.)
Recovery
●Functional recovery – Functional recovery after surgery (ie, for activities of daily living and independent activities of daily living) is highly variable in older adults. Factors influencing recovery include preoperative physical conditioning, depression, and serious postoperative complications. On average, following major abdominal surgery, recovery to preoperative levels of function may require three to six months [189].
●Cognitive recovery – Older adults experiencing postoperative delirium are likely to have a longer length of hospital stay, discharge to a nursing home, and development of dementia and/or cognitive decline. Some older adults never return to their preoperative cognitive baseline. Prevention and treatment of temporary or persistent neurocognitive decline are discussed in separate topics. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies" and "Delirium and acute confusional states: Prevention, treatment, and prognosis", section on 'Outcomes'.)
●Hospital readmission – A 2024 retrospective cohort study that included 3,552,9065 Medicare patients ≥65 years old who were followed up after a surgical procedure, 9.0 percent had emergency department visits and 9.5 percent were readmitted within 30 days [160]. In a large Medicare database study that included more than 560,000 patients, the rate of admission to an inpatient hospital within 30 days after outpatient surgery was significantly higher in patients ≥80 years of age [165].
SUMMARY AND RECOMMENDATIONS
●Age-related physiologic changes – Aging is associated with a progressive loss of functional reserve in all organ systems, with considerable individual variability in the onset and extent of changes in the (see 'Impact of age-related physiologic changes on anesthetic care' above):
•Nervous system – Pharmacodynamic changes in the central and peripheral nervous systems resulting in increased sensitivity to anesthetic agents
•Cardiovascular system – Vascular stiffening and autonomic changes leading to blood pressure (BP) lability
•Respiratory system – Decreased overall pulmonary reserve
•Liver function – Decreased hepatic mass, function, and blood flow, resulting in slower metabolism of most anesthetic agents
•Kidney function – Variable declines in glomerular filtration rate, creatinine clearance, and renal functional reserve
•Pharmacokinetic changes – Decreased total body water and increased adipose tissue resulting in pharmacokinetic changes for many anesthetic agents (eg, higher effective drug concentrations and prolonged effects)
●Preanesthetic consultation – An example of a checklist for optimal preoperative assessment of the older patient is shown (table 1). Particular attention is paid to (see 'Preanesthesia consultation' above):
•Anemia – Anemia due to iron deficiency, chronic disease/inflammation, malnutrition, or bone marrow malfunction is common (see "Diagnostic approach to anemia in adults", section on 'Older adults') [6]. Timely management is necessary, as discussed separately. (See "Perioperative blood management: Strategies to minimize transfusions", section on 'Treatment of anemia and iron deficiency'.)
•Frailty – Identification of frailty in the preoperative period helps to inform patient and family discussions regarding surgical techniques, postoperative recovery strategies, and likely outcomes. (See 'Assessment for frailty' above and "Frailty".)
The role of prehabilitation is discussed separately. (See "Overview of prehabilitation for surgical patients".)
•Cognitive function – Older patients are informed about possible postoperative exacerbation of any preexisting cognitive impairment (eg, confusion, inattention, memory problems). However, these effects of anesthesia and surgery are usually temporary. Details are discussed separately. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies".)
•Current medications – An accurate prescription and over-the-counter medication history identifies drugs potentially relevant for anesthetic care. (See 'Management of current medications' above.)
•Role of palliative care – A palliative care consultation may improve end-of-life experiences for selected high-risk patients and their families, as discussed separately. (See "Benefits, services, and models of subspecialty palliative care".)
•Institutionalized patients – Challenges include dementia and the likely presence of multiple comorbidities and frailty. (See 'Challenges for the nursing home patient' above.)
●Preoperative testing – Although routine preoperative testing is not recommended before minor procedures in older adults, patient-specific or procedure-specific considerations warrant obtaining an electrocardiogram (ECG), chest radiographs (CXRs), or laboratory tests in selected patients. (See 'Preoperative testing' above.)
●Premedication – We avoid or minimize use of benzodiazepine premedication, as discussed separately. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Intravenous agents associated with higher risk'.)
●Anesthetic technique – Selection of neuraxial or another regional anesthetic, monitored anesthesia care, or general anesthesia should be guided primarily by the requirements of the surgical procedure, coexisting disease(s), the need to prevent postoperative complications, and patient preferences. (See 'Choice of anesthetic techniques' above.)
●Anesthetic agents
•General considerations – Strategies to avoid excessive anesthetic depth and other side effects of anesthetic agents (eg, hypotension) include (see 'General considerations' above):
-Reducing doses
-Increasing the interval between repeat doses
-Using shorter-acting agents
-Brain function monitoring such as electroencephalography (EEG)
•Intravenous (IV) agents – Considerations for IV anesthetic agents (eg, propofol, etomidate, ketamine) and opioids are discussed above. (See 'Intravenous anesthetic and adjuvant agents' above.)
•Inhalation anesthetics – For all inhalation agents, the minimum alveolar concentration (MAC) at 1 atmosphere preventing movement in 50 percent of patients during surgical incision decreases by approximately 6 percent per decade after age 40 years (figure 2 and figure 3 and figure 4). We initially target an age-adjusted end-tidal anesthetic concentration (ETAC) to maintain adequate anesthesia (while avoiding excessive anesthetic depth), then continuously monitor and titrate anesthetic concentration according to the individual's responses. Neuromonitors such as EEG may also be useful to guide titration and maintain optimal anesthetic depth. (See 'Inhalation anesthetic agents' above.)
•Neuromuscular blocking agents (NMBAs) – We select shorter-acting NMBAs and use these sparingly because age-related reductions in hepatic metabolism and renal excretion may prolong duration of NMBA action. (See 'Neuromuscular blocking agents' above.)
●Hemodynamic management – Some older patients require an intraoperative mean BP target higher than the typically targeted 65 mmHg, particularly those with chronic hypertension, as discussed separately. (See "Anesthesia for patients with hypertension", section on 'Determination of target blood pressure values'.)
●Temperature management – Perioperative hypothermia is more frequent, pronounced, and prolonged in older compared with younger adults. Prevention and management of hypothermia are discussed separately. (See "Perioperative temperature management".)
●Postoperative pain management – Despite an age-related decrease in pain perception, postoperative analgesia is important. Multimodal combinations of opioids, nonopioid agents (eg, acetaminophen, nonsteroidal anti-inflammatory agents [NSAIDs], dexmedetomidine, or steroids such as dexamethasone or methylprednisolone) may be used, as well as neuraxial and regional analgesic techniques. (See 'Postoperative pain management' above.)
●Outcomes – Although older age is one risk factor, other factors include the American Society of Anesthesiologists (ASA) risk score (table 4), preoperative comorbidities, overall physical condition (ie, frailty and functional reserve), risk factors for delirium, urgent or emergency surgery, invasiveness of the surgical procedure. Functional recovery, cognitive recovery, and need for hospital readmission are other outcome measures. (See 'Outcomes' above.)
ACKNOWLEDGMENT —
The editorial staff at UpToDate acknowledge Jeffrey H Silverstein, MD, who contributed to an earlier version of this topic review.
