Regional analgesia can often be extremely beneficial for elderly pa¬tients. One advantage of regional techniques is Ihe reduced amount of narcotic needed. The disadvantages include (he hemodynamic changes associated with epidural local anesthetics and the potential for intravas¬cular injection, infection, bleeding, and nerve damage. When a regional anesthetic block is performed before a painful stimulus Ue, surgery) is initialed, pain relief lasts longer than would be expected from the pharmacokinetics of the local anesthelic. When the pain does recur, it is less intense, and lower doses of narcotic can be used. The mechanism for this phenomenon appears to occur at the spinal cord level and in¬volves modulation of the impulses eventually received in the brain.
Regional analgesic techniques range in complexity from instillation of local anesthelic into the surgical incision lo specific nerve blocks to continuous epidural infusions of local anesthetic, a narcotic, or a com¬bination of the two. The choice of technique depends on the surgical site and the relative complexity and potential advantages or disadvan¬tages of a particular technique.
Pain relief after limb surgery is often accomplished with a single-dose nerve block or a continuous infusion. For hand and elbow procedures, the axillary approach is used to block the brachial plexus because this approach can be used with relative ease and it has a lower incidence of complications than the other approaches to this plexus have, if a need for prolonged analgesia is anticipated, a catheter is inserted and an infu¬sion of local anesthetic is begun postoperatively. Often an infusion of bupivcicainc 0.125% is sufficient for complete pain relief. The infusion rate is usually started at X to 10 mL/h and titrated to desired effec¬tiveness.
After knee procedures, a continuous femoral sheath catheter tech¬nique can be used. Although the sciatic nerve is not blocked with this approach, patients still receive adequate analgesia. The femoral cathe-ler infusion may be supplemented by low-dose narcotics or ketorolac. For both the axillary and femoral sheath blocks, a blunt tip needle may be used. The same needle may be used for both single-dose and contin¬uous infusion techniques. The distinct pop felt when the needle enters the sheath signals an excellent end point for proper needle placement. This pop is much more evident with the blunt needles than with the traditional B-bevel needles. Also, with the blunt needles, entering the adjacent artery is more difficult, and the incidence of nerve damage is decreased.
Epidural analgesia: After hip. abdominal, or (horacic procedures, a continuous epidural technique is often used for analgesia. An infusion of bupivacaine 0.125% to 0.0625% solution containing fentanyl 4 to 5

usually provides excellent analgesia. When the epidural cathe¬ter is placed at the dermatome level where discomfort is perceived, the amount of local anesthelic and narcotic can be reduced, minimizing (he possibility of toxicity. For hip procedures, a lumbar, epidural catheler placement is used; for abdominal procedures, a low-thoracic, epidural catheter placement is used; and lor thoracotomies, a niidthoracic, epi¬dural catheter placemen! is used. Fenlanyl is lipophilic and does not spread widely in the epidural space, so the catheter must be placed close to the segmental area of Ihe lesion. The need for precise catheter placement can he circumvented by using epidural morphine, which spreads more readily in the epidural space. However, the rostral spread of morphine may result in late respiratory depression.
The most common complication is inadvertent removal of the cathe¬ter during routine nursing care. Meticulous taping of Ihe catheter and nursing education can reduce (his problem. Urinary retention second¬ary to the local anesthetic and Ihe narcotic occurs and is more prevalent in elderly men. Migration of the catheter to the subcutaneous tissues or the spinal space can also occur. The former results in a lack of pain relief; the latter can result in disastrously high spinal anesthesia. Fortu¬nately, the latter rarely occurs.
In an elderly patient, an epidural infusion must be titrated precisely, and intravascular volume must be maintained by close monitoring of fluid status. Blood loss of 300 lo 500 ml, from a hip wound drain can result in severe hypotension in an elderly palient with a sympathetic blockade if volume resuscitation is nol promptly instituted.
Posloperalive pain control in the elderly patient is best accomplished by a dedicated, functioning pain control service. Strict attention to the patient’s hemodynamic parameters and mental status along with a thor¬ough understanding of the altered effects of various medications in the elderly are essential. Cooperation between the surgical, nursing, and pain service staffs can provide safe and effective analgesia for even the most frail elderly patient.

Rehabilitation may require only one discipline, but usually it draws on the coordinated efforts of more than one. When a complex problem requires expertise from several disciplines, a rehabilitation team can develop a program to coordinate therapy.
Usually, rehabilitation programs are organized around a particular type or set of problems. For example, a program may be designed to help patients recover from hip fracture, stroke, myocardial infarction, or heart surgery. The program can coordinate the needed services in an environment designed to facilitate recovery. Also, persons with similar conditions can work together (oward a common goal, encouraging each other and reinforcing the rehabilitation training.
Rehabilitation programs for geriatric patients include medical care that would not be needed for younger adults. Nurses and therapists can more easily adjust goals and the intensity of care to older patients when they arc not integrated wilh younger ones, who usually can handle more intensive, demanding therapy. Also, in segregated programs, older pa¬tients will not compare their progress wilh that of younger patients and thus become discouraged. Moreover, the social work needed to provide postdischarge care can be more readily integrated into the program.
Many different settings have geriatric rehabilitation programs, and the extent, aggressiveness, and duration of treatment varies from pro¬gram to program. Although rehabilitation may begin in the hospital, organized rehabilitation programs rarely exist there. Rehabilitation hospitals usually provide the most extensive and aggressive care and should be considered for patients who have the most potential and who can participate in aggressive intervention. Patients in rehabilitation hospitals must receive and be able to tolerate at least 3 h of therapy daily. Many nursing homes have programs as well, but they arc far less intensive. Generally, these programs are limited to 1 h daily and fewer than 5 days a week. Services may be delivered in outpatient settings or at home, but these alternatives cannot deliver the two or three daily

treatments and the variety ul services supplied in institutions. Provid¬ing care lo a disabled elderly person at home is most desirable, but it can be physically and emotionally taxing to a caregiver. The spouse may not be physically able to help, and the children may be too busy with their own families. I lome health aides are available in some com¬munities but usually cannot provide round-the-clock care. Thus, when the disability is severe, institulionalization may be necessary. Nonethe¬less, creative home care may be possible, especially for those with sub¬stantial financial resources.
At the star! of treatment, the duration of therapy must he considered and discussed wilh patients and their families because not all persons can invest the lime needed for optimal results. For example, after a hip fracture, complele rehabilitation may take 6 or 8 wk; after a stroke, it may take several months. For patients unable or unwilling to remain in a rehabilitation facility that long, the goals must be altered. Determin¬ing the goal of rehabilitation helps determine how and where lo accom¬plish it.
Rehabilitation is initialed by a physician who writes a referral con¬taining instructions lo an allied health professional. Like any prescrip¬tion, this referral is a legal document. Without it. the allied health pro¬fessional cannot treat the patient.
Because the allied health professional is carrying out (he physician’s orders, the physician establishes the goal of therapy and is responsible for the efficacy and side effects of treatment. Therefore, referrals should be appropriately detailed, including all relevant information and some initial directions. An appropriate referral would be: “Indepen¬dent in ambulation I mo poststroke. Please evaluate and (real for stabil¬ity and strength” or “3 wk posl-hip fracture. Please continue therapy for independent transfer and gait.” Although many therapisls accept vague orders such as, “Physical therapy lo evaluate and treat,” this type of order is not adequate. Physicians who are unfamiliar with writ¬ing orders to therapists should consult with senior therapisls, physia-trists. or orthopedic surgeons.
Before prescribing any exercise program, the physician should deter¬mine that the patient is medically stable and advise the (herapisl about any chronic cardiac, pulmonary, neurologic, or musculoskeletal limita¬tions. Older patienls may have several problems, and treatment must often be priorilized. Physicians should work closely wilh therapists lo decide which problems to work on first and when lo move on lo others.
A physiatrist, a physician who specializes in rehabilitation medicine, treats patienls wilh disabilities, coordinating a learn of physicians and allied health professionals, and helps puticnls develop and implement a comprehensive treatment plan. I his plan is not limited to the hospilul but extends lo Ihe patient’s community, family, friends, occupation, and lifestyle.

Epidural analgesia: After hip. abdominal, or (horacic procedures, a continuous epidural technique is often used for analgesia. An infusion of bupivacaine 0.125% to 0.0625% solution containing fentanyl 4 to 5

usually provides excellent analgesia. When the epidural cathe¬ter is placed at the dermatome level where discomfort is perceived, the amount of local anesthelic and narcotic can be reduced, minimizing (he possibility of toxicity. For hip procedures, a lumbar, epidural catheler placement is used; for abdominal procedures, a low-thoracic, epidural catheter placement is used; and lor thoracotomies, a niidthoracic, epi¬dural catheter placemen! is used. Fenlanyl is lipophilic and does not spread widely in the epidural space, so the catheter must be placed close to the segmental area of Ihe lesion. The need for precise catheter placement can he circumvented by using epidural morphine, which spreads more readily in the epidural space. However, the rostral spread of morphine may result in late respiratory depression.
The most common complication is inadvertent removal of the cathe¬ter during routine nursing care. Meticulous taping of Ihe catheter and nursing education can reduce (his problem. Urinary retention second¬ary to the local anesthetic and Ihe narcotic occurs and is more prevalent in elderly men. Migration of the catheter to the subcutaneous tissues or the spinal space can also occur. The former results in a lack of pain relief; the latter can result in disastrously high spinal anesthesia. Fortu¬nately, the latter rarely occurs.
In an elderly patient, an epidural infusion must be titrated precisely, and intravascular volume must be maintained by close monitoring of fluid status. Blood loss of 300 lo 500 ml, from a hip wound drain can result in severe hypotension in an elderly palient with a sympathetic blockade if volume resuscitation is nol promptly instituted.
Posloperalive pain control in the elderly patient is best accomplished by a dedicated, functioning pain control service. Strict attention to the patient’s hemodynamic parameters and mental status along with a thor¬ough understanding of the altered effects of various medications in the elderly are essential. Cooperation between the surgical, nursing, and pain service staffs can provide safe and effective analgesia for even the most frail elderly patient.

Regional analgesia can often be extremely beneficial for elderly pa¬tients. One advantage of regional techniques is Ihe reduced amount of narcotic needed. The disadvantages include (he hemodynamic changes associated with epidural local anesthetics and the potential for intravas¬cular injection, infection, bleeding, and nerve damage. When a regional anesthetic block is performed before a painful stimulus Ue, surgery) is initialed, pain relief lasts longer than would be expected from the pharmacokinetics of the local anesthelic. When the pain does recur, it is less intense, and lower doses of narcotic can be used. The mechanism for this phenomenon appears to occur at the spinal cord level and in¬volves modulation of the impulses eventually received in the brain.
Regional analgesic techniques range in complexity from instillation of local anesthelic into the surgical incision lo specific nerve blocks to continuous epidural infusions of local anesthetic, a narcotic, or a com¬bination of the two. The choice of technique depends on the surgical site and the relative complexity and potential advantages or disadvan¬tages of a particular technique.
Pain relief after limb surgery is often accomplished with a single-dose nerve block or a continuous infusion. For hand and elbow procedures, the axillary approach is used to block the brachial plexus because this approach can be used with relative ease and it has a lower incidence of complications than the other approaches to this plexus have, if a need for prolonged analgesia is anticipated, a catheter is inserted and an infu¬sion of local anesthetic is begun postoperatively. Often an infusion of bupivcicainc 0.125% is sufficient for complete pain relief. The infusion rate is usually started at X to 10 mL/h and titrated to desired effec¬tiveness.
After knee procedures, a continuous femoral sheath catheter tech¬nique can be used. Although the sciatic nerve is not blocked with this approach, patients still receive adequate analgesia. The femoral cathe-ler infusion may be supplemented by low-dose narcotics or ketorolac. For both the axillary and femoral sheath blocks, a blunt tip needle may be used. The same needle may be used for both single-dose and contin¬uous infusion techniques. The distinct pop felt when the needle enters the sheath signals an excellent end point for proper needle placement. This pop is much more evident with the blunt needles than with the traditional B-bevel needles. Also, with the blunt needles, entering the adjacent artery is more difficult, and the incidence of nerve damage is decreased.

Narcotic analgesics have been the traditional mainstay of postopera¬tive pain control. However, before ordering a narcotic, the physician should consider its effect and side effects. The same dose given to a young adull and an older adult will have a stronger effect on the older one. In older patients, important clinical side effects are usually dose related and include sedation, confusion, respiratory depression, and constipation. Despile these concerns, by far the most common error in narcotic use is undermedication.

Intramuscular injections produce initially high plasma drug levels that can cause undesirable side effects; then the levels rapidly decline, lead¬ing to <i recurrence of pain. Thus, patients are alternately overdosed and uncomfortable. In an alerl older person, meticulous titration of nar¬cotic in the recovery room followed by patient-controlled analgesia pro¬vides excellent pain relief. Patient-controlled analgesia provides a more stable blood level of medication, avoiding the roller-coaster effects of IM dosing.
Unfortunately, not every elderly patient is a candidate for patient-controlled analgesia. A confused or demented patient cannot safely or effectively use this method. If regional techniques and nonsteroidal ?inli-inflammatory drugs are ineffective or inappropriate, a continuous narcotic infusion may be useful. Fentanyl is an appropriate choice be¬cause of its relative lack of hemodynamic side effects. However, hepatic clearance of the drug is decreased in the elderly. Also, the drug is lipophilic, and Ihe increased proportion of body fat in the elderly leads to an increased volume of distribution. These factors increase the elimination lime in the elderly. Because the volume of distribution and clearance of a drug cannot he precisely determined for an individual patient, the proper loading dose and infusion rale must be estimated. In the recovery room, patienlscan be given fentanyl 15 to 25 ?g IV q 5 min until the desired analgesic effect is reached. The goal is to avoid exces¬sive sedation or respiratory depression while maintaining blood pres¬sure and pulse within acceptable limits. Once a patient is made com¬fortable with a loading dose of I’cnlanyf in the recovery room, an infusion can be started at ! ^g/kg/h. The patient should then be moni¬tored in the recovery room for at least 2 h, so that the infusion can be adjusted. On the surgical unit, hourly nursing assessments of vital signs, respirations, mental status, and arousability should be per¬formed. Often, such intense monitoring is available only in a step-down or intensive care unit

Controlling postoperative pain in Ihe elderly can be difficult. The major goal of such control is paCieni comfort; a secondary goal is de¬creased morbidity and mortality. Adequate analgesia may improve car¬diovascular and pulmonary function. By preventing Ihe stress response to postoperative pain, adequate analgesia may also lower the incidence of postoperative myocardial events.
Much of the decrease in ventilatory function after thoracic and ab¬dominal surgeries results from surgical trauma and splinting from post¬operative pain. Postoperative analgesia cannot undo the decrease in ventilatory function produced by surgical trauma or lung resection. However, anesthesiologists and surgeons can help prevent splinting by providing adequate analgesia, thus helping patients breathe deeply and cough, improving mucous removal and avoiding atelectasis. Ry avoid¬ing atelectasis, patients also reduce the risk of postoperative pneumo¬nia and hypoxia.
Patients who receive adequate postoperative pain relief generally walk earlier and are discharged sooner than those who do not. Thus, adequate analgesia helps in achieving the overall goal of most surgical procedures: to return the patient to an improved functional state in the community, which benefits both Ihe patient and society. Also, by short¬ening the hospital stay, adequate analgesia reduces the cost of medical care.
To achieve postoperative analgesia, an anesthesiologist may use a narcotic, a nonsteroidal anti-inflammatory drug, or a regional anes-Ihelic method. Each choice has its advantages and disadvantages as a modality for analgesia in the elderly

Other Considerations
Obtaining vascular access to use monitoring devices and to adminis¬ter drugs, fluids, and blood can be a challenge in the elderly. Arthritic changes can make inlubalion and positioning for surgery difficult. Also, increased skin fragility makes the elderly person prone to injury from restraining devices, tape, Bovie pads, and adhesive monitoring devices such as HCG electrodes. Extra padding should be placed on operating tables, and care should be exercised in positioning extremi¬ties to avoid injury.
The elderly also have significant problems with perioperative tem¬perature regulation. Heal production is reduced as a result of their lower basal metabolic rate. Thinning of the skin and loss of subcutane¬ous fat make the skin a less effective insulator, so that body heat con¬servation is also impaired. The relative increase in body surface area wilh respect to body mass and the impaired vasomotor response in oldcrpersons predispose them to heat loss. Duringanesthesia, the ther¬moregulatory center in the hypothalamus is anesthetized; patients are pharmacologically paralyzed and given sympathetic blocking agents. Thus, heat production is prevented, and heat loss is promoted.

General anesthesia provides loss of conscious¬ness, amnesia, analgesia, and a variable degree of muscle relaxation. Generally, the patient’s airway is secured with an endotracheal lube, and ventilation is controlled. Most of the general anesthetics are potent myocardial depressants and vasodilators. The metabolism of these drugs is governed by the pharmacokinetic factors described above.
The dosage requirements for the induction agents propofol, midazo¬lam, and thiopental arc significantly reduced in the elderly. Ketamine and elomidate have been suggested as induction agcnls of choice for geriatric patients because of their minimal effects on the cardiovascular system, but little information is available about the effect of age on ex¬act dose requirement. The volatile anesihelics halothane. enflurane.

and isoflurane impair the already allenuated chemoreceptor response in the elderly. Also, the minimal alveolar concentration of these agents decreases linearly with age.
The muscle relaxants pancuronium and tubocurarine have an in¬creased duration of action in Ihe elderly because the termination of their activity depends largely on renal and hepatic clearance. This is not true of the shorter-acling neuromuscular blockers atracurium and ve¬curonium. Few data are available on the effects of aging on succinyl-choline activity, but it is commonly held that the longer circulatory time in the elderly allows more time for hydrolysis of the drug, so that a larger initial dose may be necessary.
The duration of action of opioids is also prolonged in the elderly be¬cause clearance is decreased and sensitivily to these drugs is increased. The sedative and respiratory depressant efl’ccls of opioids may contrib¬ute to the postoperative pulmonary complications frequently observed in this age group.
In hip fracture surgery, both regional and general anesthesia are used, and considerable debate exists over which is the best technique with respect to early and late survival and the incidence of postopera¬tive thromboembolic disease and confusion. Investigators have found no difference in the incidence of postoperative confusion between el¬derly patients who had regional anesthesia and those who had general anesthesia for hip fracture repair. The current consensus is that spinal anesthesia has no advantage over general anesthesia in improving ei¬ther short-term or long-term outcomes in elderly patients undergoing surgical hip repair. Regional anesthesia does provide some protection against deep venous thrombophlebitis, but it is not associated with a sustained improvement in outcome.

Depending on the circumstances, the anesthesiologist may provide monitored anesthesia care, regional anesthesia, or general anesthesia.
Monitored anesthesia care: When patients do not need analgesia for a procedure or when the surgeon administers it, the anesthesiologist pro¬vides monitored anesthesia care, which consists of monitoring the pa-tient”s vital signs and providing sedation as needed. Procedures such as cataract surgery, pacemaker placement, inguinal hernia repair, and ex¬tracorporeal shock wave lithotripsy are often done with monitored an¬esthesia care.
Regional anesthesia: This type of anesthesia includes spinal anesthe¬sia, epidural anesthesia, and blockade of other major nerves such as the cervical or brachial plexus. Procedures of the lower abdomen, pelvis, and legs can be done wilh spinal or epidural anesthesia in certain pa¬tients. Spinal or epidural blockade produces profound sympathetic block, which can precipitate hypotension in patients with inadequate volume status. In the elderly, epidural anesthetics have a faster onset and a greater spread; the duration of action can be prolonged because of reduced clearance. Whenever possible, adjuvant therapy with anti¬cholinergics should be avoided because of the high risk of inducing de¬lirium and other complications.

Most elderly patients have existing medical problems, which are su¬perimposed on age-related physiologic changes, complicating manage¬ment for the anesthesiologist. A thorough history and physical exami¬nation is an inlegral part of forniulaling an anesthesia plan lor the elderly patient. A review of previous hospital records or an interview with family members or friends can help define the patient’s medical history. A list of the patient’s medications can also provide important information about disease processes. The conditions of particular im¬portance to the anesthesiologist are described in TABLE 28-3.
One of the best sources of information is the elderly patient’s pri¬mary care physician, who may have records of past medical history, functional status, medications, and allergies. Frequently, lest results obtained to prepare a patient for anesthesia can be compared wilh ear¬lier results available from the primary care physician.