[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Anaesthesia and ICU](https://durgical.com/en/anaesthesia/) › [By patient and by surgery](https://durgical.com/en/anaesthesia/areas/by-patient/) › The older patient

# The older patient

- Patient and surgery

Anaesthesia for older adults, who have less reserve, take more medicines and are more prone to confusion, falls and slow recovery after surgery.

Updated Nov 13, 2026

## Key points

- Older patients have less organ reserve and need less anaesthetic: start low, go slow, and expect hypotension at induction.
- Postoperative delirium is common, often hypoactive and missed; it predicts longer stay, loss of function and death.
- Avoid benzodiazepines, anticholinergics and pethidine where possible; review the medicine list for delirium-causing drugs.
- Screen frailty, cognition and goals of care before surgery; capacity must be assessed for consent.
- For hip fracture, early surgery and a fascia iliaca or femoral block reduce pain and opioid use; regional and general anaesthesia give similar outcomes.

## What it is

Ageing reduces the reserve of every organ, even in people who seem well, and disease and frailty add to it. The heart and vessels stiffen, so blood pressure swings more with changes in volume and depends on the atrial contribution to filling; baroreflexes are blunted, so induction often causes marked hypotension. The lungs lose elasticity, airway closure occurs during normal breathing, gas exchange worsens and the responses to low oxygen and high carbon dioxide are weaker; protective airway reflexes are less brisk, raising aspiration risk. Kidney and liver function decline and body fat rises relative to water, so drugs last longer, and the brain is more sensitive to anaesthetics, opioids and sedatives, so requirements fall. Many older patients take several medicines, some with anticholinergic or sedative effects, and some have cognitive impairment that may not be recorded. Assessment therefore includes frailty, cognition, function, nutrition, medicines and the patient's goals of care, and consent requires a check of capacity. There is no single best anaesthetic: regional and general techniques both work, and the evidence does not show one clearly prevents delirium. What matters is gentle titration, keeping blood pressure near the patient's usual level, avoiding drugs that cause delirium, warming, careful positioning, opioid-sparing analgesia and early return to glasses, hearing aids, food and walking.

## What changes in this patient

- Heart: stiff ventricle and vessels, reliance on atrial filling, blunted baroreflex and beta-adrenergic response.
- Lungs: loss of elasticity, airway closure during tidal breathing, weaker response to hypoxia and hypercapnia, weaker cough and swallow.
- Kidney and liver: lower clearance; body composition with more fat and less water changes drug distribution.
- Brain: lower anaesthetic requirement, greater sensitivity to opioids and sedatives, risk of delirium and longer-term cognitive decline.
- Frailty, polypharmacy, malnutrition, sensory loss and fragile skin, bones and joints.
- Poorer temperature control: hypothermia develops faster and recovers slower.

## Anaesthetic plan (and why)

- Assess frailty, cognition, function, nutrition and goals of care, and check capacity — guides choices and consent.
- Review all medicines, stopping or avoiding those that cause delirium when safe — fewer drug-induced complications.
- Keep fasting short, with clear fluids until the permitted time — less dehydration and hypotension.
- Reduce and titrate induction and maintenance doses, and consider processed EEG depth monitoring — avoids excessive depth and hypotension.
- Keep blood pressure near the patient's usual level, with a vasopressor ready — the brain, heart and kidneys tolerate hypotension poorly.
- Pad and position gently, warm actively and protect the skin — fragile tissues injure and cool easily.
- Use regional blocks and multimodal opioid-sparing analgesia — good pain control without sedation reduces delirium.
- Return glasses, hearing aids, orientation, food and early walking promptly — non-drug measures prevent delirium.

## Ageing changes and what the anaesthetist does about them

| System | Change with age | What it means |
| --- | --- | --- |
| Cardiovascular | Stiff heart and vessels, blunted reflexes | Hypotension on induction; keep pressure near baseline |
| Respiratory | Less elasticity, airway closure, weaker reflexes | Faster desaturation, aspiration and pneumonia risk |
| Renal and hepatic | Lower clearance | Longer drug effects; titrate and space doses |
| Nervous system | Higher sensitivity, less cognitive reserve | Less anaesthetic needed; delirium risk |
| Skin, bone, temperature | Fragile tissues, poor thermoregulation | Careful positioning, padding and warming |

## Risks and complications

- Postoperative delirium, and perioperative neurocognitive decline that can last months.
- Hypotension at induction and during surgery, with myocardial injury, stroke or acute kidney injury.
- Aspiration, atelectasis and pneumonia from weak airway reflexes and reduced cough.
- Prolonged drug effects: oversedation and respiratory depression after opioids or sedatives.
- Hypothermia, pressure injuries and positioning injuries to nerves, skin and joints.
- Urinary retention, falls and loss of independence after discharge.

## Next step

- Screen for delirium every shift after surgery with a validated tool, and treat causes first: pain, hypoxia, infection, urinary retention, drugs.
- Mobilise early and involve the family and a geriatric team where available; continue sensory aids and normal sleep.
- Call a senior when delirium is severe, hypotension persists or the patient's goals of care need discussion.
- Restart usual medicines deliberately and review new sedatives before discharge.
- Plan discharge with function, falls risk, home support and follow-up of cognition.

## Test yourself

Think of the answer, then tap the question to see it.

## Why does an older patient often become hypotensive at induction?

Stiff vessels, reliance on preload, blunted baroreflexes and a lower drug requirement mean the usual induction dose causes vasodilation the body cannot offset.

## Which drug groups are best avoided to reduce postoperative delirium in older patients?

Benzodiazepines, anticholinergics and pethidine, together with other strongly sedating drugs, where safe alternatives exist.

## Does regional anaesthesia prevent delirium after hip fracture surgery compared with general anaesthesia?

Current evidence shows similar outcomes; avoiding excessive depth, hypotension and deliriogenic drugs, and giving good analgesia matter more than the technique.

## What should be assessed before surgery in a frail older patient besides the usual history?

Frailty, cognition and capacity, function, nutrition, medicines and the patient's goals of care and wishes.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/anaesthesia/the-older-patient/)

## Elsewhere in DurgiPedia

- [Comprehensive geriatric assessment: function, cognition, falls](https://durgical.com/en/clinical-exam/comprehensive-geriatric-assessment-function-cognition-falls/)
- [Nursing the older adult: functional assessment and geriatric syndromes](https://durgical.com/en/nursing/nursing-the-older-adult-functional-assessment-and-geriatric-syndromes/)
- [Pressure injury staging](https://durgical.com/en/nursing/pressure-injury-staging/)
- [Informed consent: elements and how to obtain it](https://durgical.com/en/medical-ethics/informed-consent-elements-and-how-to-obtain-it/)

## Connections

## Related 9

- [Postoperative delirium](https://durgical.com/en/anaesthesia/postoperative-delirium/)
- [Awareness and depth of anaesthesia](https://durgical.com/en/anaesthesia/awareness-and-depth-of-anaesthesia/)
- [Which medicines to continue or stop before surgery](https://durgical.com/en/anaesthesia/which-medicines-to-continue-or-stop-before-surgery/)
- [Intraoperative hypotension](https://durgical.com/en/anaesthesia/intraoperative-hypotension/)
- [Orthopaedic surgery: tourniquets, cement and blood loss](https://durgical.com/en/anaesthesia/orthopaedic-surgery-tourniquets-cement-and-blood-loss/)
- [Peripheral nerve blocks in principle](https://durgical.com/en/anaesthesia/peripheral-nerve-blocks-in-principle/)
- [Perioperative hypothermia and shivering](https://durgical.com/en/anaesthesia/perioperative-hypothermia-and-shivering/)
- [Positioning and its injuries](https://durgical.com/en/anaesthesia/positioning-and-its-injuries/)
- [Consent for anaesthesia](https://durgical.com/en/anaesthesia/consent-for-anaesthesia/)

## Related conditions 8

- [Frailty syndrome](https://durgical.com/en/conditions/frailty-syndrome/)
- [Delirium](https://durgical.com/en/conditions/delirium/)
- [Dementia (major neurocognitive disorder)](https://durgical.com/en/conditions/dementia/)
- [Femoral Neck Fracture](https://durgical.com/en/conditions/femoral-neck-fracture/)
- [Intertrochanteric hip fracture](https://durgical.com/en/conditions/intertrochanteric-hip-fracture/)
- [Falls in older adults](https://durgical.com/en/conditions/falls-in-older-adults/)
- [Aspiration pneumonia and pneumonitis](https://durgical.com/en/conditions/aspiration-pneumonia-and-pneumonitis/)
- [Parkinson disease](https://durgical.com/en/conditions/parkinson-disease/)

## In Pharmacology 6

- [Benzodiazepines](https://durgical.com/en/pharmacology/classes/benzodiazepines/)
- [Opioids and antagonists](https://durgical.com/en/pharmacology/classes/opioids-and-antagonists/)
- [Paracetamol](https://durgical.com/en/pharmacology/paracetamol/)
- [Nonsteroidal anti-inflammatory drugs (NSAIDs)](https://durgical.com/en/pharmacology/classes/nonsteroidal-anti-inflammatory-drugs/)
- [Local anesthetics](https://durgical.com/en/pharmacology/classes/local-anesthetics/)
- [Propofol](https://durgical.com/en/pharmacology/propofol/)

[← All of anaesthesia](https://durgical.com/en/anaesthesia/)

Educational content; it does not replace supervised training, your institution's protocols or the anaesthetist's or intensivist's decision. It contains no doses and no ventilator or infusion settings.

Sources: [Anesthetic Considerations in the Geriatric Population](https://www.ncbi.nlm.nih.gov/books/NBK572137/) (StatPearls (NCBI Bookshelf), 2026).

## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake

Representative model, for educational purposes only.

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Source: https://durgical.com/en/anaesthesia/the-older-patient/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/anaesthesia/the-older-patient/