Abstract
Background: There has been an increase in the number of elderly patients undergoing surgery. This particular patient population have unique age related comorbidities that lead to an increase in postoperative complications involving the neurological, pulmonary, cardiac and endocrine systems. Despite advances in anesthesia and analgesia, mono-therapy with opioids continues to be the mainstay for treatment of post-op pain, which often times leads to inadequate pain control, or gastrointestinal and respiratory compromise. Regional anesthesia and multimodal analgesic regimens are promising alternatives to reduce high doses and dependence of opioids and the adverse effects that accompany. Methods: The authors searched the following databases for relevant published trials: the Cochrane Central Register of Controlled Trials and PubMed. Textbooks and meeting supplements were also utilized. The authors assessed trial quality and extracted data. Conclusions: Incorporating perioperative regional techniques and multimodal drug therapy can be a very effective approach to perioperative pain management in the elderly and cognitively impaired. Regional anesthesia can often reduce postoperative neurological, pulmonary, cardiac and endocrine complications. It has not been completely proven to improve long-term morbidity, but does improve immediate post-operative pain control. Multimodal drug therapy utilizes a variety of analgesic medications (non-opioids) in order to minimize dosages and adverse effects from opioids while maximizing analgesic effect and benefit.
Highlights
Aging is a complex and multifactorial process that encompasses all organ systems.Due to diminished physiologic reserve and cumulative effect of comorbid conditions, any stressor can interfere with physiologic homeostasis and lead to potential deleterious adverse effects.With an increase in number of elderly patients undergoing surgical intervention(s), it is important to determine the optimal perioperative therapies to maximize recovery while minimizing adverse effects for older surgical patients.One important contribution to development of perioperative complications is improper/inadequate postoperative pain therapy.Inadequate post-surgical pain management can be associated with poor interventional outcomes, decreased perioperative pain anesthesia/analgesia experience, patient and family member, dissatisfaction associated with their surgical encounter, and potential higher rates of medical complications.[1,2]
Higher degrees of postoperative pain has been associated with an increased incidence of cognitive dysfunction 25, so it would appear that adequate control of postoperative pain would decrease the incidence of postoperative cognitive impairment.varied analgesic modalities, providing different postoperative analgesic levels, may result in a varying incidence of postoperative cognitive dysfunction.This was demonstrated in a study by Block et al in which analgesic regimens consisting of regional techniques using local anesthetics were shown to provide superior pain control over systemic opioids 26 and to reduce systemic adverse effects of opioids that have been associated with the occurrence of POCD.27In addition, epidural analgesia has been shown to reduce the incidence of postoperative pulmonary complications that has been linked to an increased occurrence of POCD.[16,28,29]
Pain management in the elderly and cognitively impaired is associated with specific complicating elements surrounding perioperative events.Geriatric patients typically suffer from a greater number of co-morbid diseases, have lower organ function reserve, and demonstrate altered physiologic and pharmacologic reactions.There are unique challenges in pain assessment.For example, it may require more time for older patients to understand the pain scale due to barriers such as vision, hearing or cognitive defects.In addition, elderly patients tend to underreport pain and effective perioperative pain management requires careful assessment of pain and sensible dosing of analgesics.It is crucial to be aware of potential adverse effects (AE’s) secondary to analgesic options and to keep a close watch for adverse effect development
Summary
Aging is a complex and multifactorial process that encompasses all organ systems.Due to diminished physiologic reserve and cumulative effect of comorbid conditions, any stressor can interfere with physiologic homeostasis and lead to potential deleterious adverse effects.With an increase in number of elderly patients undergoing surgical intervention(s), it is important to determine the optimal perioperative therapies to maximize recovery while minimizing adverse effects for older surgical patients.One important contribution to development of perioperative complications is improper/inadequate postoperative pain therapy.Inadequate post-surgical pain management can be associated with poor interventional outcomes, decreased perioperative pain anesthesia/analgesia experience, patient and family member, dissatisfaction associated with their surgical encounter, and potential higher rates of medical complications.[1,2]. The aging autonomic nervous system has reduced autonomic abilities to respond to physiologic changes, stresses, surgery, pain, and anesthesia.Increases in sympathetic nervous system activity are organ specific with the gastrointestinal (GI) system and skeletal muscle as targets.Neuronal noradrenergic reuptake is reduced in the elderly resulting in an increased sympathetic tone of the heart and an increase in basal adrenal secretions.There is a loss of beat-to-beat heart rate variability during respiration in the elderly due to reduced respiratory vagal modulation of the resting heart.Decreased baroreflex sensitivity is due to increased arterial stiffness and age associated alterations of the autonomic nervous system.The autonomic nervous system and its effectors play an important role in responses to hemodynamic challenges.any imbalance of homeostatic mechanisms in patients of advanced age can result in orthostatic hypotension, exercise intolerance, increased upper body sweating, and temperature intolerance
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
