April, 2005

Regional anesthesia works well for patients of all ages, but for seniors it can provide benefits that are especially meaningful.

Most importantly, regional anesthesia obviates the need to administer opioids before patients go home. With advancing age, the rates of drug absorption, metabolism and elimination can vary widely from patient to patient, making the response to drugs unpredictable. Elderly patients can respond dramatically to even small amounts of opioids, complicating dosing and increasing the potential for over-sedation. Even with relatively low doses, the sedative effect of opioids can cause elderly patients to become confused, prolong recovery and decrease their overall satisfaction.

A good long-term regional block also provides superior pain control. Formal research and my own experience suggest that elderly patients who leave with long-acting regional blocks take less pain medication at home and sleep through the entire night relatively pain-free.

Tips for managing seniors
If you are pondering regional anesthesia for your elderly outpatients, here are two important considerations:

• Polypharmacy. It is critical to perform a thorough drug history preoperatively. For example, we consider blood thinners a contraindication for regional anesthesia, particularly spinals and epidurals, because injections can cause bleeding and hematoma. Conversely, some researchers have pointed out that regional anesthesia may have significant advantages in patients who take levodopa. Unlike general anesthesia patients, regional anesthesia patients can continue taking this drug throughout surgery and the early post-op period. Importantly, a thorough history requires special effort because elderly patients may not have an understanding of all the drugs they take.
• Patient positioning. Positioning elderly patients for regional anesthesia can require extra time and care. Some of our patients, for example, have severe rheumatoid arthritis and impaired mobility, making it difficult for them to move into the required positions and stay comfortable during block administration and surgery. To overcome this, the provider must take a deliberate, kind and gentle approach. The advantages of avoiding sedation and prolonging pain relief make it well worth this extra time and effort.

At our ambulatory surgery unit, regional anesthesia has been a boon for our elderly patients. The simple fact that their routines are disrupted and the surgical environment is unfamiliar can cause seniors to become disconcerted, and as their anesthesia provider, I take great pleasure in knowing that I have not exacerbated their unease. In fact, our elderly patients often go home aware, confident and pain-free.

Dr. Mulroy is Medical Director of the Virginia Mason Medical Center's Ambulatory Surgery Unit in Seattle, Washington. He is also Clinical Professor of Anesthesiology with the University of Washington, Seattle.