Anesthesiology clinics
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Adequate treatment of pain is of utmost importance in making uncomplicated the perioperative course for geriatric surgical patients. Effective analgesia reduces morbidity, improves patient and family satisfaction, and is a natural expectation of high-quality care. Pain treatment in older adults is more complicated than in younger counterparts, and great consideration must be given to age-related changes in physiology and pharmacokinetics. ⋯ Side effects must be minimized and organ toxicity avoided. When complications occur they may be more severe, and treatment must be prompt. Alternative plans for analgesia must be readily enacted.
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Anesthesiology clinics · Sep 2015
ReviewPostoperative Cognitive Dysfunction: Minding the Gaps in Our Knowledge of a Common Postoperative Complication in the Elderly.
Postoperative cognitive dysfunction (POCD) is a common complication associated with significant morbidity and mortality in elderly patients. There is much interest in and controversy about POCD, reflected partly in the increasing number of articles published on POCD recently. ⋯ As the number of surgeries performed worldwide approaches 250 million per year, optimizing postoperative cognitive function and preventing/treating POCD are major public health issues. In this article, we review the literature on POCD and POCI, and discuss current research challenges in this area.
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Postoperative delirium, a common complication in older surgical patients, is independently associated with increased morbidity and mortality. Patients older than 65 years receive greater than one-third of the more than 40 million anesthetics delivered yearly in the United States. This number is expected to increase with the aging of the population. Thus, it is increasingly important that perioperative clinicians who care for geriatric patients have an understanding of the complex syndrome of postoperative delirium.
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Physiology changes at the structural, functional, and molecular levels as people age, and every major organ system experiences physiologic change with time. The changes to the nervous system result mostly in cognitive impairments, the cardiovascular system develops higher blood pressures with lower cardiac output, the respiratory system undergoes a reduction of arterial oxyhemoglobin levels, the gastrointestinal system experiences delayed gastric emptying and reduction of hepatic metabolism, and the renal system experiences a diminished glomerular filtration rate. Combined, these changes create a complex physiologic condition. This unique physiology must be taken into consideration for geriatric patients undergoing general anesthesia.
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This review summarizes existing evidence relevant to the epidemiology of chronic pain in older adults, age-related differences relevant to pain, pain assessment, and important considerations regarding pain management in later life. Features unique to pain assessment in older adults include the likelihood of multiple diagnoses contributing to chronic pain, the ability of older adults to self-report, including those with mild to moderate cognitive impairment, and recognition that some older adults with cognitive impairment may demonstrate various behaviors to communicate pain. Management is best accomplished through a multimodal approach, including pharmacologic and nonpharmacologic treatments, physical rehabilitation, and psychological therapies. Interventional pain therapies may be appropriate in select older adults, which may reduce the need for pharmacologic treatments.