**9. Regional anesthesia**

Regional anesthesia (RA) may have some benefits over general anesthesia, including less thromboembolic events, confusion and respiratory problems postoperatively. Regional techniques could be utilized as a primary anesthetic modality for surgical anesthesia or could be combined with GA as an adjunctive modality to augment intraoperative and postoperative pain relief. Additionally, RA may diminish the requirement for sedative and analgesic drugs. This technique also preserves spontaneous ventilation and probable decreases postoperative complication following pelvic and orthopedic surgery [14]. However, age-related cardiovascular and sympathetic changes as well as the reduction of cardiovascular reserve may create possibly hazardous consequences. Moreover, the risk of nerve palsies, paresthesias, and other complications are increased in the geriatric population.

Peripheral blocks in the geriatric patients demonstrate satisfactory outcomes without compromising the safety of the airway or risking major hemodynamic effects. However, there are some anatomical changes including weakening of spine and intervertebral disks, fibrosis of intervertebral foramina, and reduction in fat in epidural space in these patients. Local anesthetic spread could enhance in the spinal column, and the dose of epidural medications should be decreased and given more slowly in the geriatric patients. Consequently, metabolism and clearance of

local anesthetic agents are also delayed with advanced age. The dose of local anesthetic agents would be decreased for both neuraxial and peripheral nerve blocks. Moreover, geriatric patients are more sensitive to the central effects of opioids and are at enlarged risk of apnea following neuraxial opioid administration. In addition, neuraxial anesthesia-induced hypotension usually occurs in geriatric patients. Antiplatelet medications require several days or weeks to wear off. Therefore, ticlopidine should be stopped for 14 days and clopidogrel for 7 days before neuraxial anesthesia. However, nonsteroidal anti-inflammatory drugs and aspirin could be continued.

#### **10. Intravenous sedation**

Intravenous sedation for geriatric patients is a safe and effective technique. Normally, it is utilized for mild and moderate surgical procedures especially in the rediology department and endoscopy unit [15–18]. These procedures are typically short duration and do not create severe pain. The aim of intravenous sedation for geriatric patients is to endorse the patient's safety, to minimize physical distress or pain, to provide analgesia and procedural amnesia as well as to return the patients to their baseline level of consciousness. Usually, geriatric patients are sicker with more co-morbid situations than in the younger patients. All these factors make sedation in this group a challenging task. Old age does not describe the complete indications for giving general anesthesia more habitually.

Geriatric patients have increased response to sedoanalgesic drugs with higher risks for hypoxia, respiratory depression, and apnea. Accurate assessment of the depth of anesthesia contributes to titrating drug administration to the individual patient [19]. Sedoanalgesic drugs including midazolam, fentanyl and propofol are generally used. In my sedation practice, fentanyl, midazolam and/or propofol are frequently used in a combination technique in the geriatric patients [16, 17, 20]. To date, propofol has been shown to be safe and is extensively performed for sedation and anesthesia outside the operating room. Compared to younger patients, geriatric patients may require dose reduction of midazolam and/or propofol. My previous report also confirmed that all adult patients could be discharged to the ward within 60 minutes from the end of endoscopic procedure, and the discharge time was not associated with age, American Society of Anesthesiologists physical status, and the total dose of sedative drugs [21].

#### **11. Monitored anesthesia care**

Monitored anesthesia care (MAC) is one of the most common anesthetic techniques. To date, technologic advances in the diagnostic procedures have produced an increased demand for MAC technique. Usually, MAC is suggested for geriatric patients who fear or deny general anesthesia or who are at increased risk because of age or certain concomitant medical situations. Preoperative, intraoperative and postoperative management should be performed as geriatric patients receiving general or regional anesthesia. Importantly, geriatric patients should be monitored properly by experienced personnel who are knowledgeable about pharmacokinetics and pharmacodynamics as well as qualified in airway management and resuscitation. MAC is classically selected for geriatric patients who require supervision of vital signs and administration of sedoanalgesic drugs to supplement local infiltration or regional anesthesia. Moreover, oxygen supplementation is recommended in all geriatric patients.

*Anesthetic Consideration for Geriatric Patients DOI: http://dx.doi.org/10.5772/intechopen.97003*

Medications normally used for MAC include midazolam, propofol, fentanyl, and remifentanil. However, interpatient unpredictability is noticeable with midazolam, and some geriatric patients might be delicately sensitive to its pharmacologic effects. Midazolam reduces the slope of the carbon dioxide response curve, and decreases the ventilatory response to hypoxia. Propofol retains a short contextsensitive half-life and a high plasma clearance that produce a quick awakening when utilized as the sole agent even after a sustained continuous infusion. However, propofol creates a dose-dependent effect in cardiorespiratory system [22]. To avoid undesirable effects, it is critical to decrease the initial doses in the geriatric patients. Remifentanil is an ultrashort-acting drug. Its peak effect occurs within 1-2 minutes after bolus administration [20]. Distribution and metabolism of remifentanil permit for early offset and return of spontaneous ventilation. The dose of remifentanil should be calculated to lean body mass and that geriatric patients require as much as 50%-70% dosage reduction.
