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In his 2023 book Outlive: The Science and Art of Longevity, Stanford Medical School graduate Peter Attia MD reviews available data regarding the science of aging, with an aim to helping readers achieve the highest quality of life as they grow older. He names the Four Horsemen of aging—the primary causes of declining health—as heart disease, cancer, neurodegenerative disease (including Alzheimer’s disease), and type 2 diabetes/metabolic syndrome. Attia’s recipe for extending excellent health includes early screening, regular exercise, a balanced diet, improved sleep, and emotional well-being. Anesthesiologists attend to patients of all ages, from neonates to centenarians. As individuals live longer, there’s been an inevitable increase in geriatric surgery and geriatric anesthesia. Since 1975, the number of Americans over the age of 70 has doubled. Some 80-year-olds are fit and seem to defy aging, while others present significant risks for surgery and anesthesia. Chapter 61 on Geriatric Anesthesia in Miller’s Anesthesia, 10thedition, provides a comprehensive source on the physiology, pharmacology, and clinic practice of anesthetizing elderly patients.
Is your grandmother too frail for surgery? See this link to find out.
Here are 10 factors that lead to challenging anesthetics if you’re an older patient:
- Frailty. Frailty refers to an age-related functional decline and a heightened state of vulnerability. Frail adults lose physiologic reserves. Aging involves some physiologic decline, but frail patients decline more quickly than non-frail patients. Cardiac output, respiratory reserve, glomerular filtration rate, liver function, and cognitive function all decrease with age. The graph of function versus age usually follows a declining curve, with the shapes as below:
To affirm a diagnosis of frailty before surgery, we look for five criteria: a) Unintentional weight loss >4.5 kilograms in the past year; b) self-reported exhaustion; c) less than a 20th population percentile for grip strength; d) slowed walking speed, defined as lowest quartile on a 4-minute walking test; and e) low physical activity, such that a person can only rarely undertake a short walk. Frail and severely frail patients undergoing high-risk surgery had mortality rates of 11.5% and 25.8%, whereas non-frail patients undergoing high-risk emergency surgery had only a 7.1% mortality rate.
- High Body Mass Index (BMI). Obesity makes every aspect of anesthesia and surgery more challenging, including intravenous line/central venous catheter/arterial line insertion, airway management, oxygenation, surgical exposure and technique, respiratory function on awakening, and mobility after the procedure. With increasing age often comes increasing weight. My colleague Michael Champeau MD, Past President of the American Society of Anesthesiologists from 2022-2023, was oft quoted as teaching, “Tell me how old a patient is and what their BMI is, and I’ll tell you how difficult the anesthetic will be.” Obesity is an epidemic in the United States, especially in urban lower socioeconomic status neighborhoods, and primarily affects Black, Indigenous, and people of color. These cultures have documented high-fat, high-sodium, and high-sugar diets, which are a significant factor in chronic diseases and in morbidity and mortality. Beware the obese geriatric patient.
- Medical comorbidities. With increasing age comes an increasing number of medical problems. The American Society of Anesthesiologists (ASA) defines an ASA III patient as one with severe systemic disease, such as poorly controlled diabetes or hypertension, COPD, a moderate reduction of cardiac ejection fraction, end stage renal disease undergoing regularly scheduled dialysis, a history of a recent myocardial infarction, a cerebral vascular accident, or coronary artery disease/stents. An ASA IV patient has a severe systemic disease which is a constant threat to life. Geriatric patients with an ASA III or ASA IV classification have increased anesthetic risk. An ASA III score is associated with a 14-fold increased risk of 30-day mortality compared to an ASA I patient, and an ASA IV score is associated with an even higher risk.
- Emergency surgery. Emergency surgery carries increased anesthetic risk. Patients have a full stomach, often have abnormal preoperative vital signs, and present with an acute medical disorder which requires immediate intervention—a recipe for unexpected outcomes. Patients over 65 years of age who have a high-risk emergency operation are at significantly increased risk of postoperative complications and death.
- Abdominal or thoracic surgery. Intraabdominal surgeries (e.g. procedures on the gall bladder, pancreatic, bowel, or stomach) or intrathoracic surgeries (e.g. procedures on the heart, lungs, esophagus or trachea) are a minority of surgical procedures, but have increased anesthetic risk due to increased chance of bleeding, infection, postoperative pain, abnormal postoperative vital signs, and/or potential difficulty with breathing postoperatively. Procedures with high risk include colorectal surgery, kidney transplant, and open radical prostatectomy. Procedures with very high risk include aortic surgery, cardiac surgery, lung resections, and transplant surgery of the heart, lung, or liver.
- Sedentary lifestyle. Many geriatric patients choose to become couch potatoes. Patients who avoid exercise, and whose lifestyle is best described as sitting and watching television or staring at a computer, phone, or video game console, are at higher risk for surgery and anesthesia.
- Shortness of breath. Shortness of breath on climbing two flights of stairs is always an abnormal symptom. Shortness of breath may be due to lung disease, heart disease, frailty, or obesity, but whatever the cause, a lack of exercise reserve is an indication for further preoperative workup if time permits, to discern the cause of the dyspnea. Physicians should treat any reversible abnormality prior to the induction of anesthesia. Per the American College of Cardiology and the American Heart Association, major preoperative risk factors for non-cardiac surgery include patients with left ventricular dysfunction and shortness of breath/dyspnea.
- Difficult airway. Geriatric patients can have high neck circumferences, fused necks, or small mouths, and can pose difficult intubations. All acute medical care follows the outline of Airway-Breathing-Circulation. Abnormal airways complicate the induction of general anesthesia, and correlate with a higher risk of cardiovascular collapse or arrest during or immediately after airway management.
- Lack of ongoing maintenance medical care. Some geriatric patients have no primary care doctor. These patients never have their blood pressure, cholesterol, ECG, or routine labs measured. This lack of year-to-year medical care can lead to undiagnosed and undertreated diseases. Many of these patients are uninsured. Uninsured patients have more than twice the rate of unplanned surgery (73% vs 33%), higher rates of inpatient mortality and postoperative complications, and longer hospital stays. Uninsured patients have higher rates of unplanned surgery for conditions that can be treated electively, with worse outcomes and longer hospital stays.
- Do Not Resuscitate (DNR) orders. A patient with a DNR order on their chart is a poor candidate for anesthesia and surgery. Because Airway-Breathing-Circulation resuscitation is fundamental to an anesthesiologist’s role, and because a DNR order is in direct opposition to this role, any acute airway or cardiac resuscitation may conflict with the ethical principle of the patient’s request for DNR. During anesthesia and surgery, if a DNR patient has decompensation of airway, breathing, or circulation, the anesthesiologist is compelled to resuscitate the patient. If your family member has DNR status, surgery and anesthesia are not good ideas.
Bottom line: If you’re old, frail, overweight, inactive, chronically short of breath, and never go to a doctor, and then one day you require an emergency abdominal surgery, you’re in for a risky ride. Take my advice—peruse the list above, consult a physician, and make lifestyle changes to become a low-risk anesthetic candidate as you advance into your twilight years.
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As for DNR status, the accepted practice is to discuss with patient/family member whether to suspend the DNR status, enact a limited DNR that does not involve chest compression, or continue with literal DNR. If this is done before surgery then the anesthesiologist will have guidance on how to deal with a potential life-threatening periop event.