Use of Neuromuscular Blocking Agents in Elderly Patients: A Narrative Review in Geriatric Medicine

Abstract

With the growing number of elderly patients undergoing surgical procedures, the use of neuromuscular blocking agents (NMBAs) in geriatric anesthesia has become increasingly relevant. Aging is associated with physiological and pathological changes that affect drug pharmacokinetics and pharmacodynamics, including reduced renal and hepatic function, altered body composition, and decreased plasma protein levels. These changes influence the onset, duration, and recovery from neuromuscular blockade, increasing the risk of postoperative residual curarization (PORC) and respiratory complications. This narrative review summarizes current knowledge on the use of depolarizing and non-depolarizing NMBAs in elderly patients, including benzylisoquinolines (atracurium, cisatracurium, mivacurium) and aminosteroids (rocuronium, vecuronium, pancuronium, pipecuronium). Age-related differences in drug metabolism, distribution, and elimination are discussed, along with the clinical implications for dosing, recovery, and safety. The role of reversal agents, including neostigmine and sugammadex, is emphasized, highlighting their efficacy and safety profiles in older adults. Special attention is given to neuromuscular monitoring, particularly objective quantitative methods as a critical tool to prevent residual blockade. Individualized management strategies, careful agent selection, and vigilant monitoring are essential to optimize safety and outcomes in elderly patients. Despite age-related pharmacological changes, appropriate use of short-acting or organ-independent NMBAs, combined with reversal agents and neuromuscular monitoring, allows for effective and safe anesthesia in the geriatric population. Future research should focus on large-scale studies to better define age-specific NMBA dosing and monitoring guidelines.

Keywords: delayed recovery; geriatric anesthesia; geriatrics; neuromuscular blockade; pharmacokinetics.