quick sheet

The geriatric patient

Lower doses, slower circulation, fragile pressure — and delirium is the complication to design against.

Top concerns

1.MAC declines ~6% per decade after 40; IV induction needs fall similarly — titrate, don't template
2.Exaggerated hypotension: stiff vasculature + blunted baroreflex; slower circulation delays IV drug effect (easy to stack doses)
3.Postoperative delirium: the signature geriatric complication — screen risk, minimize deliriogenic drugs, return glasses/hearing aids early
4.Reduced renal/hepatic clearance prolongs opioids and NMBDs — quantitative twitch monitoring matters more, not less
5.Fragile skin and joints: padding, careful tape, gentle positioning
6.Polypharmacy interactions — review the list, especially anticoagulants and psychotropics

AVOIDBenzodiazepines— Strongly associated with postoperative delirium in the elderly; rarely justified as premedication.
AVOIDMeperidine— Normeperidine neurotoxicity + delirium.
AVOIDAnticholinergics (scopolamine, diphenhydramine)— Centrally acting anticholinergics precipitate delirium.
PREFERShort-acting, titratable agents— Give less, wait longer — circulation time hides the true peak.

Edentulous mask ventilation is harder — consider leaving well-fitting dentures in for mask, out for intubation
Cervical arthritis limits extension — check range preop, not at induction
Position joints in comfortable range; osteoporotic bone tolerates little force

In the elderly, the right dose usually looks like an underdose for the first two minutes.
Delirium prevention starts preop: orientation, hydration, drug list, hearing aids.

Lower doses, slower circulation, fragile pressure — and delirium is the complication to design against.

1.MAC declines ~6% per decade after 40; IV induction needs fall similarly — titrate, don't template
2.Exaggerated hypotension: stiff vasculature + blunted baroreflex; slower circulation delays IV drug effect (easy to stack doses)
3.Postoperative delirium: the signature geriatric complication — screen risk, minimize deliriogenic drugs, return glasses/hearing aids early
4.Reduced renal/hepatic clearance prolongs opioids and NMBDs — quantitative twitch monitoring matters more, not less
5.Fragile skin and joints: padding, careful tape, gentle positioning
6.Polypharmacy interactions — review the list, especially anticoagulants and psychotropics

AVOIDBenzodiazepines— Strongly associated with postoperative delirium in the elderly; rarely justified as premedication.
AVOIDMeperidine— Normeperidine neurotoxicity + delirium.
AVOIDAnticholinergics (scopolamine, diphenhydramine)— Centrally acting anticholinergics precipitate delirium.
PREFERShort-acting, titratable agents— Give less, wait longer — circulation time hides the true peak.

Edentulous mask ventilation is harder — consider leaving well-fitting dentures in for mask, out for intubation
Cervical arthritis limits extension — check range preop, not at induction
Position joints in comfortable range; osteoporotic bone tolerates little force

In the elderly, the right dose usually looks like an underdose for the first two minutes.
Delirium prevention starts preop: orientation, hydration, drug list, hearing aids.