1.geriatrics and old age anesthesia.pptx

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1. GERIATRIC ANESTHESIA 1

2. Geriatric Anesthesia UOG, Department of anesthesia Nurhussain March 2019 2 Life is a process of continual change . There is nothing that stops, through time everything changes

3. Presentation outline Objective Introduction Theories of aging Anatomic and physiologic changes related to aging Geriatric pharmacology Anesthetic management of elderly patients 3

4. Objective s At the end of the session students will able to : List the anatomical and physiological age related changes . Mention the pharmacokinetic and Pharmacodynamics changes inline with aging. List the best possible management for elderly patient Manage geriatric patients presented for surgical interventions 4

5. Introduction A universal and progressive physiological process characterized by Declining end-organ reserve, decreased functional capacity, increasing imbalance of homeostatic mechanisms and increasing incidence of pathologic process . clinically characterized by Degenerative changes in both the structure and the functional capacity of organs and tissues or p rogressive loss of functional reserve in all organ systems 5

6. Patients aged ≥65 yrs are taken as the elderly, but there is no precise definition of ‘the aged’, ‘the elderly/ advanced age patients. Chronologic age vs physiologic/biologic age Chronologic age : a person’s age in years. Biologic age— a person’s physiologic age based on level of performance of various body systems. 6

7. Gerontology — the study of the aging process. Ageing: Is not a disease Physiological phenomena Occurs at different rates, among individuals Does not generally cause symptoms. 7

8. Physiologic age: varies from person to person and from one organ system to another. The extent and onset of these changes vary from person to person. The physiologic compensation for age –related changes is adequate, but the resultant limitation in stressful conditions like exercise ,illness ,anesthesia and surgery . 8

9. Distribution : locations in the body a drug penetrates expressed as volume per weight (e.g. L/kg) There is no specific clinical marker of the ‘geriatric’ patient, and ageing does not occur abruptly. People age at different rates. An 80 year old patient may be physiologically younger than a 60 year old patient. Chronological age - poor discriminator of individual’s surgical risk ???? 9

10. Mechanisms of aging/theory Complex multi factorial process. Two theories : Physiological and Psychosocial perspective Biological/ Physiological theories : genetic and non-genetic theories . Programmed theories and Error theories . Programmed Theories : Aging has a biological timetable or internal biological clock. 10

11. Error Theories : Aging is a result of internal or external assaults that damage cells or organs so they can no longer function properly. Many theories are a combination of programmed and error theories . These processes of aging overlap and may be defined further by the organizational level of an organism where a given process occurs. 11

12. Physiological theories: mutation accumulation, programmed cell death, cumulative environmental damage, free radical damage 12

13. Psychosocial : explains the thinking (thought) processes and behaviors of aging persons. 13

14. PROGRAM THEORY: Cells replicate a specific number of times and then die. ERROR THEORY: The structure of DNA is altered as people age due to alterations  DNA not read correctly  Results in transcription and translation malfunction  Results in aging/illness/ cancer directly, or indirectly 14

15. Progressive physiologic process characterized by : Reduced tissue / physiological function. Increased susceptibility to disease(age-related diseases). Decreased resistance to stress . The functional capacity of organ declines and co-existing diseases further contribute to this decline. 15

16. Functional reserve is the difference between maximum capacity and basal levels of function. This provides a safety margin available to meet the additional demands of surgery and healing. 16

17. By two reasons they are at greater risk for perioperative complications. 1. Age related concomitant disease : play a greater role than does age it self. Highly prone to CVS,RS,renal problem,DM,arteritis and dementia 2. Decline in basic organ function . 17

18. Surgical risk and outcome in patients 65 years and older patients depends primarily on four factors: Age The patient's physiologic status and Coexisting disease Whether the surgery is elective or Urgent. The type of procedure.   18

19. Physiology and Pathophysiology of Aging 1.CVS 19 Primary and secondary Changes in heart. Primary changes in the blood vessels. Alteration in autonomic control.

20. Changes Heart …. M orphology Myocyte number decrease Left ventricular wall thickening. sinus node cell number decrease . Conduction fiber density declines Functional changes Decrease contractility. ed myocardial stiffness. & ven.filling pressure. ed β -adrenergic sensitivity. 20

21. Changes in vasculature Vascular stiffness : stiffness increases with advancing age related to break down of elastin and collagen . Alteration in nitric-oxide induced vasodilation ???? Large vessels – elongated, tortuous and less distensible. Veins and arteries dilate and stretch with decreased strength and elasticity. 21

22. Stiffness of the aorta increase after load elevated systolic BP increase left ventricular hypertrophy, which impaired diastolic filling. Decrease ventricular compliance and increased after load combine to cause a compensatory prolongation of myocardial contraction . 22

23. Heart valves: Become fibrotic and sclerotic resulting in thickening and reduced flexibility. Aortic valve sclerosis and mitral annular calcification are common echocardiographic findings 23

24. Alteration of Autonomic nervous system Decrease β -receptor responsiveness secondary to decrease receptor affinity and alterations in signal transduction. Decreases maximal heart rate. ??? Decreased peak ejection fraction. The over all effect causes the increased peripheral flow demand to be met primarily by preload reserve , making heart more susceptible to cardiac failure. 24

25. The SNS activity increases with aging and it is controversial whether the aging process alters  –receptor response. Clinically, these autonomic changes lead to a greater likelihood of intra op erative hemodynamic liability and decrease ability to meet the metabolic demands of surgery. 25

26. Catecholamine β adrenergic receptors in the myocardium are down regulated in the elderly resulting in a decreased responsiveness to catecholamines and sympathomimetic agents. 26

27. Impairment of diastolic relaxation leads to diastolic dysfunction (DD) in the aging heart. DD and anesthesia concerns? Predisposing disease state includes; hypertension with left ventricular hypertrophy IHD hypertrophic cardiomyopathies and valvular heart disease. 27

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29. The  Frank–Starling law  of the heart describes the relationship between stroke volume  and end diastolic pressure. It states that the SV of the heart increases in response to an increase in the volume of blood in the ventricles, before contraction i.e the end diastolic volume but all other factors should remain constant.  As a larger volume of blood flows into the ventricle, the blood stretches the cardiac muscle fibers, leading to an increase in the force of contraction. 29

30. Elderly heart depends on late filling that in turn depends on left atrial pressure Elderly heart is also stiff, so the left atrial pressure must be high in order to fill the LV. This make older patients prone to have diastolic dysfunction 30

31. 31 Cardiovascular effects of aging

32. Summary Slide Aging Effects on the Heart Structural changes at the cellular level Decrease in SA cells and autonomic nerve function Thickening and calcification of heart and vessels Myocardial stiffness Decreased elasticity of vessels Decreased venous return Decreased maximum heart rate Changes in cardiac output,stroke volume and blood pressure 32

33. 2. Age-related Changes In The Respiratory system Aging lungs are physiologically and anatomically similar to the lungs of patients with mild emphysema. 33

34. Respiratory : Alteration in control of Respiration lung structure Mechanics and pulmonary blood flow place elderly patients at increased risk for perioperative pulmonary complications. 34

35. Pulmonary complications have an incidence of 5.5% and are the third leading cause of postoperative morbidity in elderly patients undergoing non cardiac surgery. 35

36. Ventilatory responses to hypoxia, hypercapnia and mechanical stress are impaired secondary to reduced CNS activity. The respiratory depressant effects of BZDs, opioids and Volatile anesthetics are exaggerated. These changes compromise the usual protective responses against hypoxemia after anesthesia and surgery in the elderly patients. 36

37. Loss of elastic recoil after reorganization of collagen and elastin in the lung parenchyma. Altered surfactant production. Decrease in lung compliance , which leads to Limited maximal expiratory flow  Decreased Ventilatory response to exercise. 37

38. Loss of elastic elements within the lung is associated with 1. Enlargement of the respiratory bronchioles and alveolar ducts, and a tendency for early collapse of the small airways on exhalation. 2. Progressive loss of alveolar surface area secondary to increases in size of the interalveolar pores of Kohn. The pores of Kohn are discrete holes in walls of adjacent alveoli. 38

39. The functional results of these pulmonary changes are : Increased anatomic dead space Decreased diffusing capacity, Increased closing capacity All the these physiological phenomena lead to impaired gas exchange. 39

40. Loss of height and calcification of the vertebral column and rib cage lead to a typical barrel chest appearance with diaphragmatic flattening. The flattened diaphragm is: Mechanically less efficient, and function is impaired further by a significant loss of muscle mass associated with aging. 40

41. Functionally, the chest wall becomes less compliant , and work of breathing is increased. Chest wall thickness decrease. Calcification of intercostal cartilage. There is a weakened muscular force. 41

42. Lung and chest wall compliance decrease with advancing age. TLC, FVC, FEV 1 and Vital Capacity are all reduced RV increases and FRC remains unchanged. These changes occur as a result of reduction in elastic support of the airways and leads to increased collapsibility of alveoli and terminal conducting airways . 42

43. Due to all these changes The elderly are more likely to suffer from apneas, periodic breathing patterns and respiratory depression after administration of opioids and benzodiazepines 43

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45. Resting PaO2 declines with age at a rate described by PaO2=100-(0.4×age)mmHg Atelectasis , pulmonary emboli and pneumonia are common post-operative complications in the elderly. 45

46. Upper Airway Protective Reflexes: Cough effectively is reduced in elderly: due to desensitization of airway epithelial cough receptors. loss of elastic tissue around the oropharynx And Laryngeal, pharyngeal and airway reflexes are less and can lead to collapse of the upper airway. highly prone to Aspiration pneumonia . 46

47. Sleep or sedative states may result in partial or complete obstruction of the airway. es in PVR and PAR occur with age and may be secondary to  es in cross-sectional area of the pulmonary capillary bed. HPV is blunted in elderly individuals and may cause difficulty with one-lung ventilation. 47

48. A progressive increase in the number of episodes of arterial desaturation during sleep occurs with advancing age a History suggestive of obstructive sleep apnoea should be sought in older patients . 48

49. Thoracic and upper abdominal surgeries have the highest pulmonary complication rate. Postoperative respiratory complications are most common in geriatric patients. Clinical tips : Increase FIO2 and Tidal volume. transfer old patients to PACU with Oxygen via nasal cannula. 49

50. Clinical tips related to Res. system Patients are often edentulous making bag-mask ventilation difficult . an oropharyngeal airway helps to maintain an open airway during anaesthesia. Osteoarthritic changes may limit cervical spine flexibility and can make tracheal intubation more difficult. Care must be taken to avoid stressing the cervical spine as fragile ligaments and bones may be injured when subjected to mechanical forces. 50

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52. Normal changes of aging in the respiratory system. 52

53. Thank you 53

54. 3. Nervous system Nervous tissue mass, neuronal density (  brain cell mass , 10-30% by age 80 ). loss of neurotransmitters like Serotonin ,dopamine ,NE and Acetylcholine. Levels of glutamate, the primary neurotransmitter in cortex, do not seem to be affected. 54

55. Coupling of cerebral electric activity, cerebral metabolic rate, and cerebral blood flow remains intact in elderly individuals. Decreases in brain reserve are manifested by decreases in functional ADL, increased sensitivity to anesthetic medications, increased risk for perioperative delirium, and increased risk for POCD. 55

56. Memory decline occurs in greater than 40% of individuals older than age 60 years. Neuraxial changes include : A reduction of the area of the epidural space, increased permeability of the dura, and decreased volume of cerebrospinal fluid. 56

57. The diameter and number of myelinated fibers in the dorsal and ventral nerve roots are decreased in elderly individuals. In peripheral nerves, inter–Schwann cell distance is decreased, as is conduction velocity . These changes tend to make elderly individuals more sensitive to neuraxial and peripheral nerve block. 57

58. That’s Why: Dosage requirements for local and general anesthetics are reduced. Administration of a given volume of epidural anesthetic results in more cephalic spread , though a shorter duration of sensory and motor block. 58

59. Elderly patients: take more time to recover from GA especially if they were disoriented preoperatively. experience varying degrees of delirium . sensitive to centrally acting anticholinergic agents . The % of delirium is less with regional anesthesia, provided there is no additional sedation. 59

60. 4. Renal system : Renal mass may decrease 30% by age 80 years. most prominent in the renal cortex. This loss correlates with a decrease in the number of functioning glomerular. RBF decrease about 10% per decade after the age of 30 There is a progressive decline in creatinine clearance with age 60

61. serum creatinine remains relatively unchanged. Why is that ? ?? This occurs because muscle mass also decreases with aging. Serum creatinine is a poor predictor of renal function in elderly patients. 61

62. it is important in proper dosage adjustment for medications that are excreted by the kidneys. Tubular function deteriorates leading to reduced Renin- aldosterone response ADH sensitivity and concentrating , as result Impairment of sodium handling , conc .ability and diluting capacity predisposes elderly pts to dehydration and fluid overload. 62

63. 5. HEPATIC  GI SYSTEMS: liver mass decline(Liver volume )decreases approximately 20% to 40% with aging. Hepatic blood flow decreases about 10% per decade. There also is a variable decrease in the liver's intrinsic capacity to metabolize drugs. Rate of biotransformation, Effects on phase I reactions predominate. 63

64.  es in HBF may decrease maintenance dose requirements in drugs that are rapidly metabolized. The pharmacokinetics of drugs that are slowly metabolized are more affected by innate liver capacity than by blood flow. Albumin production, and plasma cholinesterase synthesis is diminished . 64

65. Drugs metabolized and excreted by liver reduces clearance rate and prolonged includes like, BZDS , opioids , thiopentone and non depolarizing muscle relaxant . Esophageal and intestinal motility decrease, Gastroesophageal sphincter tone decreases. 65

66. 6. Changes in temperature geriatric patients highly prone perioperative Hypothermia.   Contributing factors include: An impaired ability to sense a colder temperature Reduced subcutaneous fat layer. Reduced heat generation due to a decline in BMR. Reduced ability to increase their metabolic rate. 66

67. Reduced ability to vasoconstric and shiver . major and long operations. Anaesthetic agents exaggerate these issues. Adverse Clinical effects : impairs coagulation, immune function, wound healing, and the clearance of some drugs. increase the frequency of wound infection. 67

68. Shivering in recovery may increase oxygen demand above respiratory capacity and may cause myocardial ischaemia as oxygen demand exceeds supply. Clinical Tips : warmed operating rooms, covering exposed body parts (especially the head), and warming surgical wash and IV fluids all reduce the incidence of hypothermia. 68

69. 7. Hematologic and immune system Hypercoagulability and DVT . Anemia are more common and the response of the marrow to anaemia is impaired. Immune responses are reduced in the elderly putting them at increased risk of infection. This is due to reduced bone marrow and splenic mass with loss of the thymus. 69

70. SKIN, HAIR, NAILS Loss of subcutaneous fat Thinning of skin Decreased collagen Nails brittle and flake Mucous membranes drier Less sweat glands Hair pigment decreases Hair thins Temperature regulation difficult 70

71. Variability of organ function with age % ORGAN FUNCTION AGE (YEARS) ‘YOUNG’ ‘AVERAGE’ ‘OLD’

72. Organ Functional Reserve: Safety Margin of Organ Capacity

73. Special Aspects of Geriatric Pharmacology 73

74. Pharmacokinetics and pharmacodynamics in the elderly. Factors that affect the pharmacologic responses of elderly patients include changes in Plasma protein binding Body content Drug metabolism Pharmacodynamics 74

75. Plasma protein binding: for Acidic drugs is albumin and for Basic drugs is α 1 -acid glycoprotein. The level of albumin decreases with age, whereas α 1 -acid glycoprotein levels increase. binding protein for acidic drugs decreases with age. binding protein for basic drugs increases . 75

76. Body Composition : Decrease in lean body mass An increase in body fat and A decrease in TBW. 76

77. A decrease in TBW  in circulating blood volume-higher than expected initial plasma concentration of drugs. D ecrease body water:  Vd for Hydrophilic drugs, reducing dose requirement because of decrease COP. Arm-brain circulation time is prolonged. 77

78. the es body fat  fat stores :  Vd for lipophilic drugs ,which may prolong clearance. 78

79. 79 Source Undetermined

80. Alterations in hepatic and renal clearance occur with aging. Decreases in liver and kidney reserve can affect a drug's pharmacokinetics profile. Polypharmacy 80

81. Generally, elderly patients are more sensitive to anesthetic agents. Less medication is usually required to achieve a desired clinical effect, and drug effect is often prolonged. 81

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83. Intravenous anesthetic agents Lower dose requirement for Barbiturates, opioid agonists, and benzodiazepines. Barbiturates: peak levels not decreasing as rapidly Benzodiazepines: accumulates in fat stores, VOD larger, and elimination slowed. Why most or nearly all drugs decrease its dose ? 83

84. 1. Increased Bolus Drug Effect; Decreased protein binding, Higher free, unbound plasma drug levels. Decreased volume of distribution Slower redistribution of drug ALL of these INCREASE target organ levels! Examples: Thiopental, Propofol. 84

85. 2. Slowed Drug Metabolism: Clearance decreases as Liver blood flow decreases Liver mass decreases Kidney function decreases Volume of distribution increases with Increased body fat, Decreased albumin levels 85

86. anesthetic agents in the elderly 86

87. The elderly require less doses for pain relief . Morphine clearance is decreased . Sufentanil, alfentanil, and fentanyl are twice as potent in the elderly, increased brain sensitivity . Remifentanil is more potent in geriatric pts . For All: infusion rates should be titrated. 87

88. NSAIDs Risk of GI bleeding is very high. contribute to the devp’t of acute renal failure in the presence of impaired renal perfusion. Fluid retention. N.B. NSAIDs should be used with caution. 88

89. Inhalation Drugs Ventilation perfusion mismatch will decrease the rate of action. Decreased cardiac output will make the onset of the action more rapid. Recovery from anesthesia with a volatile agent may be prolonged because of an increased volume of distribution (increased body fat). 89

90. MAC decreases approximately 6% for every decade. Due TO: altered activity of neuronal ion channels associated with cholinergic, nicotinic and GABA receptors. Alterations in ion channels, synaptic activity and receptor sensitivity. 90

91. The lower lipid-solubility of sevoflurane and desflurane has advantage in the elderly: More rapid control of anesthetic depth than higher lipid-solubility agents. A faster emergence from anesthesia. (desflurane vs. isoflurane: 5.4 vs. 7 mins ) 91

92. Neuromuscular blockers: The duration of drug action may be prolonged if their metabolism depends on renal or hepatic excretion . atracurium undergoes Hofmann degradation ,so, unaffected by age. 92

93. 93 Aging affects the neuromuscular junction in many ways: The distance of the junction ↑ The number of ACh vesicle ↓ Receptors of ACh ↓ Sensitivity of ACh receptors —

94. 94 Succinylcholine : This agent is metabolized by pseudocholinestrase which is not affected by the aging process. The response of succinylcholine is unaltered with aging.

95. 95 The use of the intermediate-acting agent is prudent, because even the duration of one single dose of long-acting agent may be too prolonged for the planned surgery. Fewer dose of non-depolarizing muscle relaxant will be required.

96. 96

97. Pre-op assessment A careful pre-op assessment is imperative to achieve a good outcome. a mini mental state score is very useful primarily to assess reliability of information it might prove very useful in the postoperative period. Collateral history may be important via relatives, careers and nurses. 97

98. Determine the patient’s status and physiologic reserve in the pre-anesthetic evaluation. The risk from anesthesia is more related with the presence of co-existing disease than with the age of the patient. If the condition can be optimized before surgery this should be done without delay, as long delays increase morbidity rates. 98

99. DM and CV diseases are very common. Pulmonary complications are one of the leading causes of postoperative morbidity, so, pulmonary optimization is essential. significant possibility of Depression, malnutrition ,immobility and dehydration. 99

100. It is important to determine the cognitive status of an elderly patient. Cognitive deficits are associated with poor outcomes and higher perioperative morbidity. 100

101. Co-existing medical problems. IHD ,Hypertension , COPD and stroke Arthritis Diabetes, malnutrition Dementia, Parkinson’s, sensory impairment (visual/hearing loss common). 101

102. Gastro-esophageal reflux disease (GERD) and dentition. Slower gastric emptying, deterioration in parietal cell function, a greater incidence of GERD, pharyngeal pouch and hiatus herniae. 102

103. Poly pharmacy Medications- including dose, frequency, when they were started, and any recent changes. Long-term medications should be continued. Do not forget alcohol and cigarettes. Pay particular attention to Steroids, Beta-blockers, ACE inhibitors, Diuretics, Insulin or Hypoglycemic agents and Anticoagulants. 103

104. Examination: Fluid balance Weight and nutrition are all important in the assessment. MET 104

105. Investigations : an absolute minimum of ECG Full blood count Urea and Electrolytes and blood sugar are required. Otherwise investigate as clinically indicated. 105

106. Premedication lower doses of premeds, Opioid premed is valuable only if there is severe preoperative pain . Anticholinergic are not required since salivary gland atrophy is usually present . H 2 antagonists are useful to reduce the risk of aspiration. Metoclopromide could be used to promote gastric emptying. 106

107. Airway Management: Changes with Aging Arthritic Changes: 1. Decreased cervical spine and neck mobility Osteoporotic mandibles Temporo -mandibular joint stiffness Cervical spondylitis Arthritis of atlanto-occipital joint 107

108. Nuisance/Fragile teeth/loose teeth Sometimes it is best to leave dentures in place to provide support for facemask ventilation or laryngeal mask stability . Smaller mouth opening Smaller glottic opening Smaller endotracheal tube 108

109. Endotracheal intubation in the elderly Placement of ET tube is difficult in elderly Facial shape is altered, TM joint dysfunction, loose teeth with cervical arthritis makes exposure of larynx more difficult avoid over extension of neck. Laryngoscopy and intubation induced hypertension and tachycardia should be avoided. 109

110. Remember… Airway management may be more difficult Prone to airway collapse (risk of pneumonia) Higher work of breathing (risk of hypercarbia) Lower blood oxygen levels (greater need for supplemental oxygen ) After leaving PACU, hypoxia more likely from residual drug/CNS effects

111. Local and Regional Anaesthesia Techniques Anatomic changes suggest reduced requirement for local anesthetic drugs Epidural anaesthesia likely to spread upward Onset of analgesia is rapid, Reduction in blood loss Amelioration of endocrine stress response to surgery Reduced post op thromboembolic complications Reduced post op mental confusion 111

112. Technical Problems with Regional Anaesthesia in elderly Altered landmarks Difficulty of obtaining adequate patient positioning Paramedian approach is helpful Cardiovascular changes are usually limited to fall in arterial BP. 112

113. Intra op Management There will be increased sensitivity to some agents such as volatile anaesthetics, opioids and BZDS reduced sensitivity for inotropes and vasopressors. short acting agents such as desflurane or sevoflurane. The favourable low blood/gas and tissue/blood solubility co- efficients , more rapid arousal and possibly fewer critical events in the early recovery period. 113

114. Avoid hypothermia and hypoglycemia. Fluid management : Both over hydration and dehydration cause significant morbidity. Positioning: Meticulous positioning with appropriate padding is especially important. There is an increased frequency of neuropraxia 114

115. especially ulnar neuropathy , joint contractures / stiffening and bony protuberances. Combined with a fragile skin matrix, subsequent pressure sores are common 115

116. Postoperative considerations DVT prophylaxis The risk of pulmonary thromboembolism is increased due to : 1 . Age the nature of surgery for which the elderly present, Immobility and concurrent disease such as heart failure. 116

117. Simple therapeutic options include Good hydration, Early mobilization Low molecular weight/ unfractionated heparin and calf compression devices. All patients should have a risk assessment performed preoperatively and appropriate treatment options discussed with surgical staff. 117

118. 2. Nutrition. 3. Blood sugar monitoring 4. Pain 5. Oxygen therapy 118

119. POST –OP DELIRIUM Deterioration in cognitive function in the post-op period. Transient mental dysfunction, Acute confusion, decreased alertness, misperception . Disorientation. Restlessness, agitation, fear, hallucinations and delusions, altered psychomotor activity . Fluctuating levels of consciousness and disturbed sleep wake cycles. Symptoms are worse at night. 119

120. Twice as common in the elderly 10-15% of elderly surgical patients 30-50% if undergoing cardiac or orthopedic surgery Seen after general, regional and MAC anesthetics 120

121. Acute delirium increases morbidity, delays recovery, and prolongs hospital stay. Causes Drugs e.g. anticholinergics, benzodiazepines, regular drugs omitted . Infection e.g. UTI, chest or wound . Metabolic e.g. hypo/ hypernataemia Trauma e.g. hypoperfusion, fat embolism in orthopaedics. Oxygen lack/hypercarbia Psychiatric and pain 121

122. Treatment /prophylaxis Adequate ventilation correct drug dosing and electrolyte balance. Avoid polypharmacy use drugs with short elimination half-lives and minimal active metabolites. Glycopyrolate is preferable anticholinergic agent Treatment is of underlying cause e.g. antibiotics for infection and oxygen if hypoxic. 122

123. Haloperidol 2.5m g IV increased to 5mg PRN can be used to settle an agitated patient. Thiamine and diazepam might also useful. Repeated orientation, familiar surroundings, family, sensory aids and re- establishing day-night cycles are useful “non medical” therapies. 123

124. Postoperative Cognitive Dysfunction (POCD) This more formal diagnosis requires neuropsychological testing and can present weeks or months post operatively. It resembles dementia. Impairments are seen in mood, memory, learning, language, judgment, behaviour and motor function. 124

125. POCD is associated with; increasing age, alcohol abuse, poor cognitive and functional status electrolyte abnormalities , type of surgery, Polypharmacy, drug interactions, hypnotic or alcohol withdrawal, endocrine and metabolic problems, and poor pain control. 125

126. Treatment involves correction of physiological parameters, good pain relief 126

127. Assignment Fratility test on geriatrics 127

128. Thank you Any questions?